Monday Note + - Adams Christian School

Challenges for the 21 Century:
A Gender Perspective on Nutrition
Through the Life Cycle
Papers from the ACC/SCN
25 Session Symposium, Oslo, Norway
30 March and 1 April, 1998
ACC/SCN Symposium Report
Nutrition Policy Paper #17
November 1998
Foreword and Acknowledgements
To accelerate progress in tackling malnutrition, adequate food, health, and care must be ensured
throughout the lifecycle. Good nutrition during pregnancy reduces the likelihood of low birth weight and
improves pregnancy outcomes. Promotion of growth and development in the young infant and child
leads to a well-nourished school-aged child who can participate fully in the educational process. Good
nutrition during adolescence, especially for girls, is important for their growth, development, and
wellbeing, and eventually for their children’s.
This report presents a collection of papers discussed at the 25th Session of the United Nations SubCommittee on Nutrition, held March 30 to 2 April, 1998, in Oslo, Norway. This report provides new
analysis and thinking from both nutrition research and practice. It is meant to stimulate discussion and
inform policy setting. The intended audience is a broad constituency of professionals concerned with
development, for which nutrition is an indicator of achievement and a central aim.
The ACC/SCN is most grateful to the Government of Norway for hosting its 25th Session and to the
Norwegian National Nutrition Council, especially Dr Gunn-Elin Aa. Bjr rneboe, Arnhild-Haga Rimestad
and Bodil Blaker who collaborated on the general organisation and local logistics of all the associated
Session meetings. This was the first time that an SCN Session was hosted by a donor government.
The subject of the symposium, held traditionally on the first day of the Session, was Challenges for the
21st Century: A Gender Perspective on Nutrition Through the Life Cycle. We are indebted to the
Honorary Chair and keynote speaker of the symposium, Dr Gro Harlem Brundtland, now DirectorGeneral of the World Health Organization. She was assisted in this task by Professor Kaare Norum,
then Director of the Institute for Nutrition Research in Oslo (now Rector of the University of Oslo), and a
member of the SCN's Commission on the Nutrition Challenges for the 21st Century. In addition, we
thank Dr Hilde Frafjord Johnson, Minister of International Development and Human Rights in Norway;
Professor Philip James, Chair of the SCN's Commission and Director of the Rowett Institute in
Aberdeen; Suttilak Smitasiri, Mahidol University, Thailand; Per Pinstrup-Andersen, International Food
Policy Research Institute, Washington, DC; and Alan Lopez of WHO. Our grateful thanks to Ms Isatou
Jallow Semega-Janneh of the Gambian Ministry of Health who gave a most lively and stimulating
Second Abraham Horwitz Lecture.
The SCN’s Advisory Group on Nutrition served as external reviewers for this publication. Lindsay
Barrett provided the cover illustration. Cathy Needham served as rapporteur for the Symposium. This
report was edited by Cathy Needham and Sonya Rabeneck. We are grateful to Arne Oshaug and
Gerd Holmboe-Ottesen for taking the initiative to welcome the SCN to Oslo and in generating such
enthusiastic support for the work of the SCN in Norway.
Funding received from the Government of Norway, Government of the Netherlands, and the United
States Agency for International Development (USAID) has been used towards the printing and distribution
of this publication, and is most gratefully acknowledged.
Table of Contents
Chapter 1: Overview ...................................................................................................................................................... 1
Chapter 2: Address by Hilde Frafjord Johnson, Minister of International Development and Human
Rights, Norway .............................................................................................................................................................. 7
Chapter 3: Opening Speech by Richard Jolly, Chairman, ACC/SCN ....................................................................... 11
Chapter 4: Address by Dr Gro Harlem Brundtland .................................................................................................... 15
Discussion ................................................................................................................................................................... 21
Chapter 5: The Global Nutrition Challenge in the Millennium: Presentation of the Draft Commission
Report .......................................................................................................................................................................... 25
Malnutrition in Young Children ................................................................................................................................... 26
Maternal Nutrition........................................................................................................................................................ 27
The Agricultural Dimension ........................................................................................................................................ 28
Seasonal Deprivation.................................................................................................................................................. 30
Mental and Cognitive Development of Children ....................................................................................................... 30
New Dietary Challenges: Chronic Diseases............................................................................................................. 32
Areas for Action and Ways Forward .......................................................................................................................... 33
References .................................................................................................................................................................. 35
Discussion ................................................................................................................................................................... 36
Chapter 6: Nutrition Challenges and Gender in Asia................................................................................................. 45
Nutrition in Asia: The Challenges............................................................................................................................... 45
What’s Next? .............................................................................................................................................................. 46
Nutrition Development in Thailand: Lessons Learned.............................................................................................. 46
A Practical Approach to Effective Nutrition Actions in Asia ...................................................................................... 49
Final Notes................................................................................................................................................................... 51
Acknowledgements..................................................................................................................................................... 51
References .................................................................................................................................................................. 52
Discussion ................................................................................................................................................................... 52
Chapter 7: Achieving the 2020 Vision, with Special Reference to Gender Issues .................................................. 55
The Role of Women in Achieving the 2020 Vision.................................................................................................... 58
Conclusions ................................................................................................................................................................. 60
References .................................................................................................................................................................. 61
Discussion ................................................................................................................................................................... 61
Chapter 8: Gender and Nutrition in the Global Burden of Disease, 1990 to 2020................................................... 67
Estimating Mortality..................................................................................................................................................... 67
Mortality Estimates for 1990....................................................................................................................................... 69
The Burden of Disability.............................................................................................................................................. 70
Risk Factors for Death and Disability......................................................................................................................... 73
How the Burden of Risk Factors was Assessed ....................................................................................................... 73
Results: The Contributions of Malnutrition to the Global Burden of Disease .......................................................... 73
Projections of Disease Burden, 1990-2020............................................................................................................... 75
Conclusions ................................................................................................................................................................. 77
References .................................................................................................................................................................. 77
Discussion ................................................................................................................................................................... 77
Annex: Defining a Metric to Measure Disease Burden............................................................................................ 79
Chapter 9: The Abraham Horwitz Lecture. Breastfeeding: From Biology to Policy ................................................ 83
Introduction ................................................................................................................................................................. 83
The Biology of Breastfeeding ..................................................................................................................................... 84
Global Patterns............................................................................................................................................................ 85
Barriers to Optimal Breastfeeding.............................................................................................................................. 86
Breaking the Barriers with the Baby Friendly Community Initiative – The Gambia ................................................ 87
Policy Issues................................................................................................................................................................ 90
A Challenge to SCN Member Agencies..................................................................................................................... 91
References .................................................................................................................................................................. 93
Closing Comments...................................................................................................................................................... 94
Comment from the Reviewer...................................................................................................................................... 95
Chapter 10: General Discussion ................................................................................................................................. 97
List of Tables, Figures and Boxes
Table 1: Nutrition interventions to prevent intrauterine growth retardation.............................................................. 28
Table 2: Chronic energy deficiency in India in the late 1980s.................................................................................. 28
Table 3: The epidemic of obesity in Asia and the Pacific ......................................................................................... 32
Table 4: Prevalence of subclinical deficiency by level of population risk................................................................. 34
Table 5: Anaemia during pregnancy in Asia.............................................................................................................. 46
Table 6: Modern and post-modern currents in development.................................................................................... 49
Table 7: The ten leading causes of death, 1990....................................................................................................... 69
Table 8: The leading causes of disability, world, 1990 ............................................................................................. 70
Table 9 : Ten leading causes of disease burden (DALYs), developing world, 1990 ............................................... 72
Table 10: Global burden of disease and injury attributable to selected risk factors, 1990 ...................................... 74
Table 11: Burden of disease attributable to underweight among children, 1990 ..................................................... 75
Table 12: Gauging the severity of disability................................................................................................................ 82
Table 13: Exclusive breastfeeding and median duration of breastfeeding: a global and regional
overview, 1996 ............................................................................................................................................ 86
Figure 1: Total numbers of underweight children by region, 1995........................................................................... 26
Figure 2: The hidden impact of undernutrition........................................................................................................... 26
Figure 3: Projecting progress in reducing underweight in children ......................................................................... 27
Figure 4: Projected food needs of the Indian population......................................................................................... 29
Figure 5: A new approach to prioritising village, regional and national policies..................................................... 29
Figure 6: Survival curves according to season of birth in rural Gambia ................................................................. 31
Figure 7: Development quotient of stunted children treated differently .................................................................. 31
Figure 8: Causes of death in the developed and developing world, 1996.............................................................. 32
Figure 9: BMI distributions in adult populations (male and female) ........................................................................ 33
Figure 10: Secular trends in dietary fat and the prevalence of obesity in Danish army recruits ............................. 34
Figure 11: Total population observed from 1950 to 1990 and projected from 1990 to 2050, by continent ............ 47
Figure 12: Thailand holistic health and nutrition development process.................................................................... 48
Figure 13: Deaths by broad cause group, 1990......................................................................................................... 68
Figure 14: The burden of disease, by broad cause group, 1990 .............................................................................. 71
Box 1:
Box 2:
Box 3:
Box 4:
Box 5:
Box 6:
Members of the Commission on Nutrition Challenges in the 21st Century ................................................... 25
Global nutrition security.................................................................................................................................... 30
Areas for action................................................................................................................................................. 34
A new global compact for nutrition .................................................................................................................. 35
Breastfeeding: benefits for the mother ........................................................................................................... 85
Breastfeeding: benefits for the infant ............................................................................................................. 85
Chapter 1: Overview
Chapter 1
The 25th Session of the ACC/SCN was held in
Oslo, Norway on March 30 to April 2, 1998,
hosted by the Government of Norway. The
subject of the symposium, held traditionally on
the first day of the Session, was Challenges for
the 21st Century: A Gender Perspective on
Nutrition Through the Life Cycle.
This topic was inspired by debate during the 24th
SCN Session held in Kathmandu the year before.
The symposium took as its starting point the
notion that to accelerate action, malnutrition
needs to be tackled throughout the lifecycle by
ensuring adequate food, health, and care. Good
nutrition during pregnancy reduces the likelihood
of low birth weight and improves pregnancy
Promotion of growth and
development in the young infant and child leads
to a well-nourished school-aged child who can
participate more fully in the educational process.
Adolescent nutrition, especially for girls, is
important for their growth, development and
wellbeing, and eventually for their children’s.
This report presents the proceedings of the
symposium. This overview summarises the
content of the individual presentations, as well as
the main issues discussed during the plenary.
The Honorary Chair of the symposium was Dr
Gro Harlem Brundtland, now Director-General of
the World Health Organization. She was
assisted in this task by Professor Kaare Norum,
Director of the Institute for Nutrition Research in
Oslo, and a member of the SCN's Commission
on the Nutrition Challenges for the 21st Century.
Introductory remarks were made by Dr Hilde
Frafjord Johnson, Minister of International
Development and Human Rights in Norway.
Following the opening session, Dr Richard Jolly,
Chair of the SCN, introduced Dr Brundtland, who
gave the keynote address. Following the
opening session, Professor Philip James, Chair
of the SCN's Commission on the Nutrition
Challenges for the 21st Century and Director of
the Rowett Institute in Aberdeen, presented the
main themes of the Commission’s work.
Subsequent presentations were given by Suttilak
Smitasiri (Mahidol University, Thailand), Per
Pinstrup-Andersen (International Food Policy
Research Institute, Washington, DC), and Alan
Lopez (WHO). At the end of the day, Dr Jolly
introduced Ms Isatou Jallow Semega-Janneh of
The Gambian Ministry of Health who gave the
second Abraham Horwitz Lecture.
Dr Hilde Frafjord Johnson welcomed participants
to Norway and to the SCN's 25th Session. She
drew attention to the fact that the goal set at the
World Food Conference in 1974, to eradicate
hunger within a decade, was not achieved. The
subsequent World Food Summit held in Rome in
1996 called for governments to take prime
responsibility for action in their countries. Dr
Johnson spoke of an �enabling environment’ for
development that includes the functioning of the
world trade system, efforts to provide effective
debt relief, and appropriate macro-economic
reforms lead by the Bretton Woods Institutions.
She spoke of the feminisation of poverty,
stressing that a poverty-oriented policy in
development is a gender-oriented policy. Dr
Johnson noted that the Norwegian government
has identified education and health as top
priorities in their cooperation with developing
countries. An important aspect of this work is
taking a human rights approach, whereby people
are fully active in the development process and
have established rights.
Given that this was the 25th Session of the SCN,
Dr Richard Jolly in his opening address offered
remarks on the origins of the SCN, which first
met in 1977. From its beginnings, the SCN has
involved agencies of the United Nations, bilateral
agencies and non-governmental organisations.
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
He gave tribute to Professor Nevin Scrimshaw
who, some twenty years before the SCN was
created, saw the need for the agencies to
collaborate on technical issues of nutrition. Dr
Jolly highlighted the many accomplishments of
the SCN, noting especially the work of Dr
Abraham Horwitz and Dr John Mason, past Chair
and Technical Secretary. Under their leadership,
the SCN issued a series of reports on the world
nutrition situation and important lessons learned
from successful community nutrition action
programmes. This work provides a very rich
source of material to draw upon in mobilising
accelerated action into the next century.
When introducing keynote speaker Dr Gro
Harlem Brundtland, Dr Jolly noted Norway's
commitment to development assistance, which
far exceeded the 0.7% target for many years. Dr
Jolly wished Dr Brundtland every success in her
new role of leadership for health in the United
Nations. In her keynote address, Dr Brundtland
posed the question: how can we best stimulate
positive change in political processes? The Hot
Springs discussions of some 55 years ago
identified poverty as the first cause of hunger and
However, the fundamental
objectives set out then have not been achieved:
namely orderly management of domestic and
international investment, and sustained
international economic equilibrium. However,
with more democracy in the world today, we
have more opportunities to implement sound
Dr Brundtland cited a policy in Norway as an
example of a national action to alleviate a public
health problem. A national nutrition and food
policy was formulated in Norway in the seventies.
This policy emphasised reducing fat intake and
increasing intake of fruits and vegetables as
priority actions. Advocacy was underpinned by
economic and social polices that influenced
household choices, as well as the production,
distribution, and pricing of food. Despite some
significant delays in implementation, this policy
eventually resulted in a widespread change in
dietary preference for low-fat milk, now widely
available in food outlets throughout the country.
Dr Brundtland highlighted the need for consistent
effort to get good policies implemented,
especially when there are strong interest groups
working against the public health interest.
Dr Brundtland went on to stress the need for
targeted policies to improve nutrition in
developing countries, noting that economic
growth and more equity will not necessarily
improve nutrition.
The importance of
micronutrient interventions to health outcomes
has not been sufficiently emphasised. Vitamin A
interventions, known to have a dramatic effect on
young child mortality, are but one example.
Dr Brundtland also discussed changes to be
introduced into WHO's work. She stressed that
capacity building and health sector development
will be part of all WHO programmes. The WHO
will also speak out on the need to safeguard the
role of health and social services. This message
will be directed not just to the financial
institutions, but also to governments. Finance
ministers of all countries need to hear about the
central role of health for development. Evidencebased health and nutrition policies will serve this
task well, she said.
In closing, Dr Brundtland likened the SecretaryGeneral's team of UN agency heads as his
cabinet, and the Secretary-General himself as a
Prime Minister. Mandates of agencies need to
openly discussed at this level, and integrated.
Only with this kind of thinking will the goals that
have been set out by the global conferences be
Professor Philip James began his presentation
titled �The Global Nutrition Challenge in the
Millennium’by explaining the origins of the SCN's
Commission on the Nutrition Challenges of the
21st Century and introducing its members. The
Commission was established following the SCN's
discussions in Kathmandu one year ago. Its
purpose is to identify the emerging nutrition
challenges and to examine the role of the United
Nations agencies in meeting these challenges.
Professor James began by presenting numbers
and trends in preschool malnutrition, noting that
some 157.6 million children are underweight
worldwide, according to 1996 figures published
by the ACC/SCN. According to simulations
carried out by the International Food Policy
Chapter 1: Overview
Research Institute (IFPRI), by the year 2020, at
current rates of progress, about 150 million
children will still be underweight. Importantly, the
definition of malnutrition conventionally used for
these estimates hides the true impact of
malnutrition on societies. This is because the
majority of children may have depressed growth,
even when only modest numbers are specified
as malnourished, because they fall below a given
Professor James then traced the origins of young
child malnutrition to low birth weight, and to low
body mass (BMI) in women and poor weight gain
during pregnancy. Evidence from a review of
randomised controlled trials of nutrition
interventions during pregnancy shows that poor
foetal growth responds to nutritional
interventions. "We need to look at antenatal
care in a completely new way in order to avoid
the huge handicap that arises from low birth
weight", he stated.
In introducing the agricultural dimension,
Professor James covered several points. Firstly,
if being well-nourished ensured growth to an
optimum height, in India for example, one-third
more food would be needed. Secondly, reliance
on only a small number of food crops introduces
an element of vulnerability and risk in terms of
sustainable development. Thirdly, seasonal
fluctuations in the annual provision of food
significantly affect adult and infant nutrition. This
may have profound long-term implications on the
development of societies.
Professor James also addressed the issue of
dietary chronic disease. He noted that in
numerical terms, diseases of the circulatory
system and cancers are now greater in the
developing world than in the industrialised world.
There is also a profound rise in rates of obesity in
developing countries. Some of these problems,
diabetes for example, have foetal origins and
major implications for policy. Professor James
summed up by saying "... with a coherent public
health strategy ... not simply adult education...
the course of coronary heart disease can be
In conclusion, Professor James urged that
coherent strategies need to be formulated in
relation to the magnitude of the problem and the
level of population risk. This has been done by
the Institute of Medicine for three micronutrient
deficiencies, and a similar approach could be
developed for the range of malnutrition problems
that societies face.
Dr Suttilak Smitasiri's presentation on "Nutrition
Challenges and Gender in Asia" focused first on
the experience of Thailand in tackling
undernutrition in children. The speaker drew
attention to the high rates of underweight in
children in Asia, and anaemia among pregnant
women. Anaemia of pregnancy is especially
widespread, over 80% in India and Bhutan.
Thailand is known for having dramatically
reduced malnutrition in young children, from over
one half to about 19% within one decade. What
were the elements of this success? Dr Smitasiri
pointed out that policies and programmes were
created to reduce both poverty and malnutrition.
Targeting poor areas, focused interventions, a
primary health care structure that promoted
community participation, and a strong emphasis
on nutrition in rural income generation schemes
were important elements.
Advocacy and
commitment at the highest political levels were
also key. These aspects were galvanised by a
small group of senior professionals with strong
backgrounds in primary health care and
management. This group was effective in
merging nutrition work into the national poverty
alleviation plan. Because of the massive scale of
implementation, and high levels of volunteer
recruitment at the village level, results were
communicated widely, which helped to raise
How relevant is this experience to other countries
in Asia? Dr Smitasiri outlined some of the
contrasts between the situations of South Asian
women and Thai women. In Thailand, women
and men have both been involved in nutrition
policy implementation. However, there are three
important gender differences that might limit
application beyond Thailand: 1) South Asia faces
more difficulties in terms of food production and
living standards, 2) South Asia has a wider
economic and social gap between the �haves’
and the �have nots’, and 3) the role of women in
South Asia is more limited than in Thailand and
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
elsewhere in South-East Asia. Systematic efforts
are needed to create a critical mass of leaders,
especially women leaders in South Asia.
Nutrition work needs to build upon a solid
understanding of the potential for change.
The speaker noted in conclusion that "the Thai
experience .. can be considered by other Asian
countries," and despite the need for urgent action
in South Asia, she cautioned that nutrition work
should not dis-empower the poor.
In his paper "Achieving the 2020 Vision," Dr Per
Pinstrup-Andersen first expanded on the six
priority areas of action required to realise the
2020 Vision set out by the IFPRI:
strengthen the capacity of developing
country governments to perform appropriate
functions, such as maintaining law and order
and assuming private sector competition in
markets. "The efforts of the past decade to
weaken developing country governments
must be turned around", he stated.
Governments should facilitate food security
by facilitating a social and economic
environment that provides all citizens with
the opportunity to assure their food security.
invest more in poor people to enhance their
health, nutrition and productivity, and to
increase their access to remunerative
employment. Female education is among
the most important investments for assuring
food security.
accelerate agricultural productivity by
strengthening agricultural research and
extension systems.
Agriculture is the
lifeblood of the economy in most developing
countries, providing up to three-quarters of
all employment and half of all incomes.
Agriculture has long been neglected in
developing countries resulting in stagnant
economies and widespread hunger and
promote sustainable agricultural intensification and manage natural resources soundly.
Local control over natural resources must be
strengthened and local capacity for management improved.
develop effective low-cost agricultural input
and output markets. Policies and institutions
that favour large-scale, capital intensive
enterprises over small-scale labour-intensive
ones should be removed.
expand and realign international assistance.
The current downward trend in international
development assistance must be reversed,
but aid effectiveness also needs to be
improved. Recipient countries should
develop a coherent strategy for achieving
goals related to food security and poverty
and should identify the best use of
international assistance.
Dr Pinstrup-Andersen went on to discuss the role
of women in achieving the 2020 Vision, noting
that women account for 70-80% of household
food production in Sub-Saharan Africa despite
unequal access to land, inputs, and information.
Overlooking the potential benefits from effective
integration of women into development is costly
to developing countries. It also results in fewer
development gains per dollar spent on
development projects. The human resource
embodied in women is poorly utilised in the
development process.
Extensive research done by IFPRI has shown
that improvements in household welfare depend
not only on the level of household income but
also on its control. Women tend to spend their
income disproportionately on food and other
family needs. Thus women's incomes are more
strongly associated with improvements in child
health and nutrition. Further, ensuring nutrition
security of the household through a combination
of food, health care, and child care is almost
exclusively the domain of women. Technology is
urgently needed to increase the productivity of
In conclusion, the speaker stressed that women
are key to food security, and must be given equal
access to productive resources and to education,
health care, and other factors that increase their
wellbeing and their human capital.
Dr Alan Lopez, in his presentation "Gender and
Nutrition in the Global Burden of Disease", began
by explaining the origins of the Global Burden of
Disease (GBD) project. Statistics on health
status traditionally have enormous limitations that
affect their practical value to policy makers.
Health statistics tend to be partial and
Chapter 1: Overview
fragmented, and sometimes misused by
advocates competing for scarce resources. Also,
traditional health statistics do not allow policy
makers to compare relative cost-effectiveness of
different interventions. Working together, the
World Bank and the WHO in 1991 commissioned
a study of the Global Burden of Disease to
provide a full assessment of global health
conditions. The results of this work have been
widely published. Two main findings arise from
the mortality analyses:
for several major developing regions (Latin
America and the Caribbean, for example)
more people die of non-communicable than
communicable diseases. In China, for
example, there are more than four times as
many deaths from non-communicable than
communicable causes;
only in India and sub-Saharan Africa do
communicable causes still predominate.
However, analysis of mortality outcomes does
not give a full picture of a population's health.
The leading causes of disability are much
different from the leading causes of death. The
central role of disability in determining overall
health status "has until now been almost
invisible", Dr Lopez stated.
The GBD team has shown that the leading
causes of disability include, surprisingly,
depression and other mental illnesses. Irondeficiency anaemia is ranked second among
leading causes of disability. Turning to the issue
of sex differences, Dr Lopez underlined that
women suffer disproportionately from their
reproductive role. The burden of reproductive illhealth, almost entirely confined to developing
regions, is so great that, worldwide, maternal
conditions make up three of the ten leading
causes of disease burden in women 15 to 44
Where does malnutrition figure in these
estimates? To deal with this question Dr Lopez
presented data on exposures to hazards.
Exposure to particular hazards can significantly
increase an individual's risks of developing
disease. Policy makers need solid information
on these risk factors to devise effective
prevention strategies. The burden of disease or
injury that can be attributed to past exposure to a
given risk factor is an estimate of the burden that
could have been averted if that risk factor had
been eliminated.
Importantly, of the ten risk factors studied,
malnutrition is the dominant hazard responsible
for about 16% of the global burden of disease;
poor water supply and sanitation are responsible
for an additional 6.8% of the global burden.
Malnutrition is a major cause of disease burden
in Sub-Saharan Africa where it accounts for onethird of all disability life-adjusted years (DALYs)
lost and in India where it accounts for 22% of
DALYs lost. These estimates do not capture the
effects of mild and moderate underweight in
children, micronutrient malnutrition and other
forms of undernutrition in other age groups. This
important work is yet to be done.
The importance of taking into account
malnutrition as an underlying cause of mortality
was stressed during plenary discussion of Dr
Lopez's paper. Similarly, for Eastern Europe and
countries of the former Soviet Union, the
importance of overnutrition and poor nutrition to
declining health and rising rates of premature
mortality was underlined.
Ms Isatou Jallow Semega-Janneh spoke on
“Breastfeeding: From Biology to Policy", as the
second Abraham Horwitz Lecturer. The theme of
her presentation was exclusive breastfeeding.
She began by reviewing aspects of the biology of
breastfeeding, pointing out that "the full benefits
of breastfeeding may not be realised if optimal
breastfeeding, including exclusive breastfeeding,
is not practised". Citing data available from
WHO's Global Data Bank on Breastfeeding, the
speaker noted that exclusive breastfeeding to the
age of four months is quite rare despite very high
initiation rates, especially in Africa. In describing
barriers to exclusive breastfeeding, Ms SemegaJanneh notes that local perceptions of what
constitutes optimal infant feeding may differ
greatly from international recommendations.
The speaker then described an innovative
community action project, called the Baby
Friendly Community Initiative, which was carried
out in The Gambia beginning in 1991. The
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Initiative focused on providing community
support to exclusive breastfeeding. The rationale
for this approach was that most deliveries in The
Gambia occur at home and feeding practices,
including breastfeeding, are influenced to a great
extent by traditional beliefs at home.
The Ten Steps of the Baby Friendly Hospital
Initiative were adapted to the community level.
Messages on maternal nutrition, complementary
feeding, environmental sanitation, and personal
hygiene were also incorporated. Village support
groups on infant feeding were created. These
groups— made up of five women and two men—
were trained to implement and monitor the
Initiative. Traditional birth attendants were
included in the support groups because of their
key role in the communities. Training built on
local and traditional knowledge. Village support
groups were entirely responsible for information
During the lifetime of the
Initiative, breastfeeding initiation rates (within 24
hours) increased from 60.2% to 99.8%. Similarly,
exclusive breastfeeding became universal.
Attitudes also changed and a local term for
exclusive breastfeeding was adopted. Rest
houses in the field were constructed for
breastfeeding women. Because of the success of
the Initiative, national expansion in The Gambia
has been recommended.
The speaker then reflected on the importance of
maternity protection for all working women, and
explained how different aspects of maternal
protection are covered in existing international
instruments, such as the Innocenti Declaration
and others. Ms Semega-Janneh concluded by
challenging the SCN member agencies to "bring
home the importance and benefits of
breastfeeding to governments and their policy
Chapter 2: Address by Hilde Frafjord Johnson
Chapter 2
Address by Hilde Frafjord Johnson
Minister of International Development and Human Rights, Norway
Distinguished delegates, ladies and gentlemen, it
is an honour and a pleasure for me to welcome
you all to Norway and to Oslo. You are faced
with one of the most daunting challenges for the
21st century: the elimination of hunger and
malnutrition, with particular emphasis on a
gender perspective on nutrition through the life
cycle. At the World Food Conference in Rome in
1974, it was decided to eliminate hunger within a
decade. We did not succeed with this important
moral obligation— far from it, in fact. Poverty and
the great division between the rich and poor in
the world today present us with a moral
imperative. We cannot refuse to become
involved in the fight against poverty and
malnutrition. Globally, there are more than 800
million chronically hungry people and 160 million
malnourished children under the age of five.
Twelve million children under the age of five die
annually and 50% of these die of malnutrition.
Billions of people suffer from illnesses related to
bad nutritional habits and millions of people
suffer from famine as a result of natural disasters
and conflict. These numbers must go down and
we have to contribute to their reduction.
support national efforts. The failure by rich
countries to fulfil the UN target of 0.7% of GNP
for official development assistance is
unacceptable. The reduction in the aid budgets
of the donor countries must be reversed.
There is no simple solution to the elimination of
malnutrition and hunger. The challenge before
us is immense. If we are to solve this problem
we have to supply a broad range of measures.
The UN, donor countries, civil society, and
developing countries must work together in a
coordinated manner to contribute to its
elimination. The Declaration and Plan of Action
of the World Food Summit in Rome, 1996,
recognised that governments must take the
prime responsibility for action in their own
countries. National policies will have to put the
interests of poor and starving people first. The
international community has an obligation to
In 1988, I spent a year in a village in Tanzania
doing fieldwork for my thesis in social
anthropology. I lived and worked among village
farmers, and measured at close range how
international prices affected government
subsidies (and the lack thereof), and how
adjustment programmes affected local women
and their families. Make no mistake about it,
these seemingly abstract, almost academic
structural phenomena about which we publish
books, papers, and articles are matters
determining the lives of millions of people. An
assistance programme is not of much use unless
it takes these conditions fully into account.
The international community must make
extensive efforts to improve the enabling
environment for development. Among our most
important tasks are:
to improve the functioning of the world trade
system through the World Trade Organization, taking into account the poorest
to support the efforts to provide effective
debt relief through, for example, the Paris
to support, although not necessarily without
criticism and conditions, macro-economic
reforms lead by the Bretton Woods Institutions.
In addition, national policies and aid resources
are crucial in order to attain development goals in
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
the poorest countries. In this regard, the 20/20
Initiative is of great importance. On the basis of
this Initiative, launched at the Social Summit in
Copenhagen, donor countries should allocate
20% of their development aid to basic social
services, such as primary education and basic
health care. Likewise, developing countries
should allocate 20% of their own budgetary
resources to the same end.
The implementation of the 20/20 Initiative should
be a top priority, and is also a pre-condition for
reaching results in the area of gender and
nutrition for the 21st century. Women are often
the prime producers in the households. They
take responsibility for the children and take care
of meal preparation and family nutrition.
Investing in education for women and reaching
women with basic health services are
investments in the future. It gives a lot in return
in food security and nutrition and in health and
prevention. That is why gender should be our
prime focus.
The development efforts by many countries are
currently being complicated— some might even
say jeopardised— by the lack of coordination
among donors. Tanzania has to relate to some
30 donors at the same time, each with often very
different demands and agendas. There are
around 3000 projects in the country. Each
project might in itself be worthwhile, but they are
not necessarily a result of priorities stated by the
government. Often they are more a result of the
donors’ own priorities.
This diverse and
uncoordinated project portfolio might instead be
a serious impediment to development. In fact,
our presence can do more harm than good. The
host government might have to use most of its
resources to follow up all the donor projects, and
have less time and even fewer resources to set
their own agenda for development and to
implement a comprehensive strategy for
sustainable economic growth. We have to get
our act together in all donor furore to strengthen
donor coordination. In this context, everyone has
to let go of self-interests. I am calling for a
comprehensive approach to the fight against
poverty and malnutrition. What matters are
results on the ground, among the poor— not at
There is now broad support for emphasising
women in development. Most of us recognise
the importance of the role of women for
economic and social development. On the other
hand, we have a long way to go before we can
say that we are anywhere near equality between
the sexes in most countries. The question is how
to best fight inequality and discrimination against
women, and thereby establish an environment
that leads to development. Statistics show that
70% of the world’s poor are women. This is
often called the feminisation of poverty.
Statistics show that 70% of the world’s
poor are women. This is often called
the feminisation of poverty.
A key element in any strategy to eliminate
malnutrition and reach women is targeting the
poor. We have to target the poorest countries,
the critical sectors of health, education, and
agriculture, and the poorest parts of the
population. Our goal is not to feed people, but to
enable people to feed themselves. We have to
stimulate income-generating activities in the
private sector.
Only through growth and
productivity will people find work, incomes grow,
and families be fed.
A poverty-oriented policy in development is a
gender-oriented policy. Fighting poverty and
achieving food security are two sides of the same
struggle. A key to positive results is improved
access to education, health care, employment,
land, technology, and credits for the poorer segments of the population. However, environmental degradation and population growth
threaten to disrupt the equilibrium between
people and resources. Increased investment in
agriculture is needed, not least in the poorest
developing countries where agriculture contributes a major share of GNP, employment, and
exports. We must implement sustainable rural
development policies that ensure stable food
supplies and food security for all. Supply of
micro-credits to female entrepreneurs is one way
to mobilise women in the private sector.
The Norwegian government has put education
and health at the top of the priority list in its
Chapter 2: Address by Hilde Frafjord Johnson
cooperation with developing countries. By
educating girls and improving primary and
maternal health care, we contribute to lowering
population growth, to increasing family incomes,
and to reducing gender inequalities. We reach a
number of development goals simultaneously.
Reducing poverty and meeting the basic needs
of individuals are in themselves, means of
promoting human rights. Adequate access to
food and nutrition is a fundamental human rights
issue. If the right to food is not fulfilled, then
other human rights will be of less importance.
The human rights approach is an essential part
of the work for sustainable social and economic
development. With this approach, people are not
just defined as beneficiaries with certain needs,
but recognised as active subjects with
established rights. The State is obliged to
respect, protect, facilitate, and when necessary,
to realise these rights.
By educating girls and improving
primary and maternal health care,
we contribute to lowering
population growth,
to increasing family incomes,
and to reducing gender inequalities.
As for all human rights, the right to adequate
food and nutrition must be guaranteed without
any form of discrimination as to national or social
origin, race, gender, language, religion, political
or other opinions. It is inherent in the definition of
the right to adequate food, that food should never
be used as an instrument for political or
economic pressure. In the case of nutrition and
malnutrition, it is crucial to keep the gender
dimension in view. It has repeatedly been
documented that in many societies girls and
women are exposed to poverty and malnutrition
more so than boys and men. Malnutrition among
women has severe consequences for the next
generation. Poor maternal nutrition results in low
birth weight infants, which in turn leads to
increased health risks during childhood and
adolescence. Therefore, it is vital to keep in mind
the gender dimension in our struggle for better
conditions for the millions of people living in
It is my hope that this symposium will help
increase involvement and knowledge in this area
and stimulate further action.
Ladies and gentlemen, it is not the case that
some human rights apply today and others
tomorrow. Nor do some, like the right to food
and basic needs, apply to us and not to them.
Nor do some apply to men and others to women,
some to the rich and others to the poor. The
obligations are universal, as are the
responsibilities for their implementation. It is no
less than that challenge we are here to take on—
realisation to the right for food and nutrition for
everyone on this planet. With these few words I
welcome you to Norway, to Oslo and to this
important conference, and wish you all the best
in your deliberations.
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Chapter 3: Opening Speech by Richard Jolly
Chapter 3
Opening Speech by Richard Jolly
Chairman, ACC/SCN
Dr Brundtland, Madam Minister, on this 25th
meeting of the SCN, I think we should realise
that we have a wonderful example of civil society
before us, and this has been part of the SCN
from its beginning in 1977. I welcome our
special guests, Dr Antezana, Deputy DirectorGeneral of the World Health Organization, Dr
Tomris Turmen, and our Horwitz lecturer this
afternoon, Isatou Jallow Semega-Janneh. I
would like to welcome the SCN members from
15 UN agencies. I would like to welcome the
members of the Advisory Group on Nutrition, of
which Dr Ricardo Uauy is currently our chair. I
would like to welcome the members of the
Commission on Nutrition, of which Professor
Philip James is chair. I would like to welcome
the many loyal and supportive friends from
bilateral agencies, with Elly Leemhuis-de Regt as
their current focal point.
I would like to also welcome the assembled nongovernmental organisations (NGOs)— I think we
have 30-40 NGOs present and perhaps a good
number more from within Norway. I would like to
mention particularly Barbara Underwood of the
International Union of Nutritional Science (IUNS)
who is with us today. She is no stranger to the
SCN and she tells me we now have three IUNS
people as part of the structure of the SCN. I
would like from within Norway particularly to
mention Arne Oshaug and Inge Nordang. The
reason we are here is because of the initiative
that Arne took last year in Kathmandu at the last
SCN Session. On the other end of the phone
here in Oslo was Inge Nordang. Between them,
they made the offer that has brought us here and
I want to say to all of you, thank you very much
for your part in getting the meeting started. I want
to mention the Secretariat members: Sonya
Rabeneck, our Technical Secretary, and Jane
Hedley, Cathy Needham, Jane Wallace, and Arie
Groenendijk, who have played such a major role
over the last year.
This is the 25th meeting of the ACC/SCN. It is
actually our 22nd year so you can say as we
embark on our 22nd year that it is our 21st
birthday. With the help of George Beaton, who
has been digging around a little in the historical
files, I would just like to say a word about the
SCN— not so much to glory in the past, but to be
inspired by some of the achievements that the
SCN has made to practical action on nutrition
worldwide. SCN’s first meeting was held 21
years ago, in September 1977 in Rome, to a
mandate established by the Economic and Social
Council of the UN (ECOSOC). The first meeting
was under the chairmanship of Graham Kermode
of the Food and Agricultural Organization (FAO).
From the beginning, the structure of the
ACC/SCN has involved what we now call civil
society. At the moment, the UN, under the
leadership of Secretary-General Kofi Annan, is
saying, �How can we reach out? How can the UN
be less of a group locked into itself just talking to
itself?’ I hope you all feel proud to be part of the
SCN which, since 1977, has been showing how
that can be done.
From the beginning, civil society, the involvement
of the advisory group of distinguished experts,
and the bilateral agencies were part of the SCN
as set down by ECOSOC. I want at this point to
praise just a few of our founding fathers: Dick
Heywood, Deputy Executive Director of the
United Nations Children’s Fund (UNICEF) and
SCN’s second chairman, who used to refer to the
triumvirate of the SCN— the agencies, the AGN
and the bilaterals; Sol Chafkin of the Ford
Foundation, who chaired the AGN; and Leslie
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Burgess, who was the first Technical Secretary.
But I want to call for special praise for an even
earlier founding father who I am delighted to see
is still with us and very actively involved—
Professor Nevin Scrimshaw, who is representing
the UNU, the United Nations University. Nevin
was one of a group that decided there was need
to bring the agencies together. He focused on
the technical issues of nutrition and helped
create, 20 years before the SCN, the Protein
Advisory Group, formerly created by Dr Candau,
then Director-General of WHO, co-sponsored by
UNICEF and with FAO joining in from the
beginning. We thank you for your vision. I am
proud that we can now build upon that.
I want to note some of the achievements that we
can see on the ground— those issues related to
nutrition action that this committee helped bring
into being.
First, the early mobilisation of action for the
control of iodine and vitamin A deficiencies. Now
major areas of action, we can say that with iodine
deficiency there have been major and
remarkable areas of success, and with vitamin A,
there has been growing success. At our 11th
meeting in Nairobi in 1985, a 10-year plan to
control vitamin A deficiency was presented at the
request of the SCN. I am also told that at that
same meeting, Basil Hetzel was asked to
prepare a paper on the control of iodine
deficiency and to form a small working group to
formulate a strategy.
Other highlights of the SCN’s contributions
include promoting nutritional concerns and
monitoring the nutritional status of refugees and
displaced persons, closely linked to the work of
the United Nations High Commissioner for
Refugees (UNHCR) and the World Food
Programme (WFP).
Thirdly, holding symposia on key topics such as
the symposium on Nutrition and Economic
Adjustment in Tokyo, 1986, under the auspices
of the UNU, which the IMF attended for the first
time. Soon after, M. de Larosier, the Managing
Director of the IMF, spoke on the need to
incorporate nutritional concerns into adjustment
policy. That speech was the first time their
Director-General had spoken out on nutritional
concerns. There was more interest in that
speech, IMF colleagues told me, than any other
that the Managing Director had given until that
time. That was the first meeting chaired by Dr
Abraham Horwitz, my very distinguished
Fourthly, under Dr Horwitz, and with the support
of then Technical Secretary, John Mason, the
series of Reports on the World Nutrition
Situation, which the SCN had long called for,
started to be produced. We have three
authoritative reports— the fourth is underway.
Fifthly and very importantly, the Nutrition Policy
Papers (formerly State-of-the-Art papers) that
drew on the experience of country-by-country
action. Some were supported by the agencies—
all are of importance for the agencies and the
others in this civil society in addressing the
question �what can be done to accelerate action
in nutrition?’ These are practical papers filled
with important lessons and focused often on
success stories.
Friends, all this has emerged from our work on
collaboration and strengthening coordination. It
has been far from perfect. We have had our
differences. We have even had our fights. But
at our best, we have made a big difference. But
not enough. As you, Madam Minister, have just
reminded us, there are still enormous problems
of nutrition and challenges of undernutrition in
the world today, and this is the focus for our
meeting today. You have summarised the
statistics of the children under five, with more
than a quarter of the world’s children in
developing countries under-nourished. Over half
of women and girls suffer from anaemia; and 5060% of children in South Asia are stunted. But
we should come to our tasks today, not in a
mood of despair, but in a mood of new
determination, because in this room is a
powerhouse of knowledge and experience, not
only on what needs to be done, but on what can
be done. We don’t have all the answers, but let
us not underestimate that we do have many of
the answers. Any one of us could go down the
list of things that we know have been applied in
Tanzania, or have been applied successfully in
Thailand, or have been used in Chile, but are not
being carried forward in other countries to
Chapter 3: Opening Speech by Richard Jolly
anywhere near the extent of this success. Last
year’s Human Development Report noted that
the world has made more progress in reducing
poverty in the last 50 years than in the previous
500 years. We know a great deal of what needs
to be done. The challenge is to mobilise
ourselves to build on this experience, to identify
the questions where we are not yet sure, but to
make sure that in the next few years we do much
more than present trends suggest.
I would like to end by quoting the words that
were quoted often by Dr Abraham Horwitz:
Keep the faith that you are committed
to a most noble cause,
the wellbeing of people,
most of whom you do not know,
whose needs you feel intensely.
Redouble your efforts in whatever you
do in nutrition, while being
bold and imaginative.
May that thought motivate and focus our minds
today, tomorrow, Wednesday and Thursday, to
make this 25th session of the SCN worthy of our
heritage. Thank you.
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Chapter 4: Address by Dr Gro Harlem Brundtland
Chapter 4
Address by Dr Gro Harlem Brundtland
Introductory paragraph by Richard Jolly
It is a great pleasure, Dr Gro Harlem Brundtland,
to welcome you. It is a special honour and
privilege for us to have your participation as
honorary chairperson for today. You agreed to
play this role even before your selection as
nominee to the high post of Director-General of
the World Health Organization. It is now
therefore a double honour for us. Your nation—
wonderful Norway— has already given the United
Nations its first Secretary-General. Your country
has inspired many of us with its principle of
internationalism and its generous humanitarian
commitments. I remind those from outside
Norway, that we are in a country that for many
years has far exceeded the 0.7% target in aid.
We thank you, Dr Brundtland, for Norway’s
intellectual contributions and leadership, and we
thank you especially for your country’s long
concern for human rights. We wish you every
success on drawing on this wonderful heritage in
what we trust will be your future role of
leadership for health with the United Nations.
Thank you very much. Dear guests and dear
participants at this symposium, our development
minister has already greeted and welcomed you
all to Norway with the enthusiasm expected from
someone with her portfolio and field of
responsibility in this country. Based on my own
experience from the Norwegian political scene,
let me first share with you my deep feelings of
gratitude that Norway’s role, profile, and
contribution to international cooperation and
humanitarian work will certainly continue as you
have known it over decades. I could applaud
every word that the development minister of the
other party— the Christian Party, now in
government— was addressing to you. There is a
strong consensus on the priorities of our
international cooperation as well as our national
nutrition policy and health policy. Indeed, the
Christian Party has been a long-standing partner
with the Social Democrats when setting our
priorities in development cooperation. I feel
confident that Norway will have a strong voice on
the alleviation of poverty, on focusing on the
countries with greatest needs, and on taking
seriously the broad human rights perspective in
our follow-up to the series of global conferences
during the last decade. We have focused on the
basic needs of health and education as being
central in an environmentally friendly and
sustainable development process. We have
focused on the key role of women in all societies,
on the importance of empowerment of women in
social development for the potential of the next
generations and for the economic prosperity of
nations and populations.
We have focused on the importance
of empowerment of women
in social development for
the potential of the next generations
and for the economic prosperity
of nations and populations.
But now, at the very outset of my speech, I
believe it is important that there is no
misunderstanding as to my platform while
addressing you. I am speaking in my own
personal capacity. I am between chairs. I am
the former, not the present Prime Minister of
Norway. I am the future, if indeed elected,
Director-General of the WHO. So I will not today
be speaking on the political and technical
priorities of the WHO. That address I will give to
the Health Assembly in May.
During the whole of this century, with the
milestones of creating our international
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
institutions, the conviction has been that we must
face common concerns and that we share the
responsibility for our common future. The
founding fathers addressed war, hunger, poverty,
and disease. This conference has links to them
all. We are still far from a world freed from these
scourges of humanity. But we have more tools
to do so, we have more knowledge, more lines of
communication, more shared experience, more
democracy and I believe we have more shared
values and beliefs— in short, we do have more
opportunities. In Hot Springs, Virginia, 55 years
ago, an act on food and agriculture, with seven
short paragraphs, was formulated. They pointed
the way ahead. They declared their belief that
the goal of freedom from want of food, suitable
and adequate for the health and strength of all
peoples, can be achieved. They declared that
there has never been enough food for the health
of all people, but that this is justified neither by
ignorance nor by the harshness of nature. They
called for concerted efforts to economise
consumption, to increase supplies and distribute
them to the best advantage. They identified the
first cause of hunger and malnutrition— poverty.
They solemnly declared it useless to produce
more food unless men and nations provide the
markets to absorb it. With full employment,
enlarged industrial production, the absence of
exploitation, increasing flow of trade within and
between countries, an orderly management of
domestic and international investment and
currencies, and sustained internal and
international economic equilibrium, the food that
is produced can be made available to all people.
They were very good at that time in formulating
short and precise documents.
They identified other important aspects. The
primary responsibility lies with each nation for
seeing that its own people have the food needed
for life and for health. Steps to this end are for
national determination, but each nation can fully
achieve its goal only by working together. These
were fine words. They were wise and it was a
good analysis 55 years ago. They still hold true,
but we can easily identify some reasons why it
went wrong. We have not achieved an orderly
management of domestic, economic and international investment, economic equilibrium, and
absence of exploitation. This is why the minister
today spoke about debt, why she spoke about
the importance of the WTO, even from a health
perspective. Our global scene and our scene
internally in nations have not met these
fundamental objectives of fairness, of an
economy that works and where democracy in a
wide sense can take the lead.
But today, we are assembled under the headline
�a gender perspective’. I know it’s a long
philosophical discussion whether �men’ also
means women, but I prefer to say it outright,
�men and women’. They spoke about men— we
must speak about women and children. We
must speak more loudly about equity and
solidarity. We must speak about nature and the
environment to secure the long-term living
conditions on earth. We must speak about
human rights. When doing so, we are in the
midst of political decision-making— of making an
impression on political decision-making, on
opinion building around the world, the allocation
of resources, the values that they build on and
the choices that are taken by governments and
societies. It raises the questions, how can we
best stimulate positive change in these political
processes? How can we move more people and
civil society to take more enlightened action?
How can we build public opinion and create the
basis for more concerted action?
programmes have been formulated and declared
at the Rio conference, in Vienna, in Cairo, in
Copenhagen and in Beijing.
I take the
perspective of the major conferences over the
last few years to illustrate an important part of the
political framework that we live in. The
conferences on environment and development,
women and human rights are as important to the
issues involved in our agenda today, as are
those mentioned in your Commission report to
this conference, where nutrition goals have been
addressed directly and have been adopted at the
World Summit for Children, the International
Conference on Nutrition, and the World Food
Just as health inequities cannot always be
resolved through action by health professionals
and experts, so nutritional action is not always
appropriate to tackle malnutrition. As concerned
citizens, as experts, policy makers or
practitioners, we know that the test of all our
efforts is only what can be measured on the
Chapter 4: Address by Dr Gro Harlem Brundtland
ground. That is the public health perspective.
Not the declarations, but the implementation on
the ground.
Poverty is the greatest polluter. This was what
Indira Gandhi, the Indian Prime Minister, said
when she came to Stockholm in 1972 to the first
Conference on the Environment. The alleviation
of poverty is still, 25 years later, a major concern
and a key challenge in all of our development
efforts. This comes clearly to the forefront also in
the report to this meeting. Poverty-related
human suffering and tragedy are still an unmet
challenge to us all. We know the effects of lack
of food, clean water, and unsafe motherhood.
Still, we are only underway in implementing the
cure and in applying the preventive and practical
steps. We know the long-term effects of
malnutrition in pregnant women and young
We know about stunting in
unbelievable numbers of children in some parts
of the world, but do we in fact realise the
terrifying long-term results when children grow to
become adults deprived of their full mental and
intellectual capacity? Do political leaders know
the consequences? There is reason to doubt it.
So we need to speak out. This is part of a major
public health problem.
Prevention of disease, disability and ill health is a
good investment in the future, not only in
humanitarian terms, but also in economic terms.
The burden of disease is at the same time the
burden of unfulfilled human and societal
When one billion adults in
developing countries are underweight, this
impairs work capacity, leads to infection, and
increases the risk to future generations. A
strategy of investing in health and education, in
meeting basic needs, cannot be questioned.
There is a long way to go in partnership and
coordinated efforts at the country, regional, and
international levels. However, we must not shy
away from taking seriously the changing total
picture of the disease burden that is related to
food, nutrition, daily life conditions and
behavioural change.
The chronic disease
burden is to a great extent linked to diet; dietdependent diseases are increasing worldwide.
Some of you in this audience feel very strongly
that these facts are not taken seriously enough
given the emerging scientific evidence. I believe
it is psychologically easy to take this attitude. If
you eat too much, it is your problem. If you eat
too little, it is everybody’s problem. The changing
total picture of nutritional deficiencies is partly
two sides of the same point as you have noted in
the Commission report.
The burden of disease is
at the same time
the burden of unfulfilled human
and societal development.
We do face a double challenge— to counter both
the consequences of dietary deficiencies, poverty
and undernutrition, and the consequences of
unbalanced overnutrition that often occur sideby-side in the same countries. Increasingly, they
pose a double disease burden. It also means a
greatly added burden on health budgets and
competes for the resources so sorely needed to
secure basic community service and health care.
Prevention is clearly called for on both these
aspects. The burden of chronic diseases is
emerging so rapidly that the developing world
already carries the greatest numerical burden. In
Central and Eastern Europe, there are
dramatically rising rates of chronic diseases and
falling life expectancy.
Let me briefly mention a Norwegian experience
when trying to link global and national concern
on food security, food production, and nutrition.
Based on the recommendations from the
FAO/WHO World Food Conference in 1974, a
national nutrition and food policy was formulated
in Norway in the seventies as a policy document
to the Norwegian parliament from the Norwegian
government. Taking into account the existing
scientific knowledge and drawing up guidelines
for the necessary regulations and economic
incentives and disincentives to be used, the
government advised a reduction in fat and an
increase in vegetables, potatoes, whole grains
and fruits, and of course, fish! We have seen
results. Teaching, information, and opinion
building have been underpinned by economic
and social policies that have an impact on
household choices, and on the production,
distribution, and pricing of food.
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
There has, from the very start, been close
cooperation and dialogue between sectors, of
course with the academic world— the experts—
but also with the different ministries of
agriculture, health, and social affairs. We have
seen results in the improvement of the disease
pattern and health indicators in Norway from this
policy that was formulated by political bodies.
And I say that because I think more countries
need to do so than those who are doing it today.
Along that road, however, I remember some
instances of slow decision making, of strong
interests that succeeded in spending an
enormous amount of effort and time producing
political and practical counter arguments to the
right cause. Although political decisions had
already been taken in principle by the Norwegian
cabinet, which also had a majority in the
parliament, it sometimes took years and years
before implementation happened. Why? I will
give you this example. The National Nutrition
Council had proposed to the government the
good idea of having a new product— low fat
milk— on the Norwegian market.
government, after a discussion, supported this,
and also agreed to price it at a lower level than
the regular milk product.
Several years later, when I had been out of
government, I asked what had happened to this
political decision, because I didn’t see the low fat
milk in the stores. What happened? I had this
explanation given to me by the cabinet ministers.
Firstly, it would have cost more for the farming
and food production sector to make this new
Secondly, it would convey the
impression that the regular milk product, for
many consumers, had too much fat. Indeed, that
message was the message! When Professor
Kaare Norum demonstrated to the public on TV
that you could indeed mix the regular milk and
the skimmed milk to achieve the wanted result,
people started doing this in practice and
gradually we were able to overcome the
resistance. We now have low fat milk, skimmed
milk and regular milk on the Norwegian market,
and what happened? Low fat milk is the product
that most households prefer. I tell you this
because it is a lesson: constructive, well-founded
policies require consistent effort. We must not
give up, even when pressure groups and strong
industrial or other economic actors are working
against us.
...constructive, well-founded policies
require consistent effort
and we must not give up,
even when pressure groups
and strong industrial
or other economic actors
are working against us.
We should never give up, we should continue.
You have said that in the struggle for
improvement in nutrition and health. I also want
to mention that the same struggle has been true
to stop the decline and then secure an increase
in breastfeeding. It started in this country in the
1960s and, when I went to the Harvard School of
Public Health, I wrote a paper that studied the
patterns of breastfeeding around the world and
looked at why we had this decline. But in the
1960s and onwards in Norway we have been
working hard to change the pattern. Babyfriendly hospitals, support of mothers, and
advocacy of best practices completely changed
the downward trend. Much work is needed on
this issue globally, however, in close cooperation
between WHO, UNICEF, and other actors in the
field. We have to speak of course with the
business sectors who are influencing in many
ways the total picture and our ability, but it has to
be done in an open and substantive dialogue on
the effects and the consequences in this area, as
well as in all others relating to nutrition and
Economic growth and more equity will not by
themselves create nutrition improvement. We
need to realise that we are dependent upon a
targeted policy to improve nutrition.
experience of South Asia shows this very clearly,
where the incidence of pre-school malnutrition
still affects half of all children. Investing in health
and nutrition can be an effective investment to
abate poverty and to improve economic growth.
Building a healthy economy
is the most direct road
to ensuring a healthy people.
Chapter 4: Address by Dr Gro Harlem Brundtland
There is one specific area of importance that I
think should be mentioned. In the most recently
produced food-based dietary guidelines of the
WHO, the importance of micronutrients has been
highlighted. There has not been sufficient
emphasis in international health on the important
contribution that micronutrients make to human
health. Look at the facts. A simple inexpensive
vitamin A capsule taken two or three times a year
by a child deficient in that micronutrient can
reduce a child’s chance of dying from measles by
some 50%, from diarrhoea by 40%, and cut the
overall risk of death by about 25%. Of course we
also know about the importance of vitamin A in
pregnancy— the risks to the foetus and newborn.
But this is only one of several examples where it
is important that we base our action on results—
substantive results— that can be advocated and
that can spread the knowledge needed for
Clear goals, advocacy, political
commitment, and community action must all be
part of the answer. This is a consistent public
health experience and approach. With primary
health care available, nutrition concerns can also
be addressed more consistently.
In these last couple of months I have addressed
the Executive Board of the WHO, putting forward
my vision, my beliefs and my view of some of the
global health issues and the role and priorities of
the WHO. I can share some of the points on
which I focused in that address. I have also
addressed the World Bank during my recent visit
to the United States and emphasised the close
partnership that will be needed between these
two important institutions for world health. I
would also like to share with you some of this,
which is related I think to the theme of this
Capacity building in countries with greatest need
must be a priority issue for the international
community. That is why I have stated my
ambition of introducing health sector
development as a dimension in all WHO
programmes. Building a healthy economy is the
most direct road to ensuring a healthy people.
The fundamental cure, as you have heard, is
economic and social development, it is the
empowerment of people— both women and
men— and it is in this overall framework that we
shall place our comeback for global health. It is
not a separate task. There are important lessons
to be learned from the way structural adjustment
programmes have been devised and carried
through. There are successes and failures and
we can learn from both so we can avoid
victimising the vulnerable by cutting essential
social services, and this we need to monitor,
measure, and address. This is the role of the
WHO— to help to do. And you can expect the
WHO to be there with its advice on sector-wide
reform, speaking out for the need to safeguard
the role of health and social services. But that
message will not only go to the World Bank and
to financial institutions, it must also reach the
governments themselves. They too, have to
make the right priorities. Health has no real quid
pro quo. It is not a question of �it is my money so
do it my way’. Health has no border and few
issues illustrate the global interdependence
During my recent visit with Jim Wolfensohn, he
said that too often health ministers are absent
from the meetings he has with governments.
That, he said, has to change, and I agree. But I
would add that we also have to remind
presidents, prime ministers, and finance
ministers that they are truly health ministers
themselves. Their overall decisions are decisive
for the wellbeing of their people. I believe that
WHO as a leading advocate in health can help
set the agenda around the world. But then we
need to provide the evidence that health is key,
not only as a moral obligation and an ethical
obligation, not only as a human right, but also
because it is pure and sound economics.
A decade ago it became widely accepted that
education, especially of young women, was
crucial for development. It still is, but now we
have new evidence, clearer evidence of the
central role of health in this context. Finance
ministers around the world need to know it. And
we need to remind them and be able to back our
statements up with facts. What we need is
evidence-based policy, i.e., evidence-based
health policy and evidence-based nutritional
policy. And this is what you in this forum help
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Health has no border
and few issues illustrate
the global interdependence better.
We need what I call the scientific underpinning of
policy, because it is the only thing that carries
solidly across borders, across the world, into all
nations, into all parts of population groups. As
communication possibilities increase, the only
real common language is science.
The Sub-Committee on Nutrition
and the ACC itself symbolise
the cross-sectoral approach
and the inter-agency cooperation
that are absolutely necessary
to address the global
nutritional challenge.
We need a broad, concerted effort, and the test
is on the ground at the local, national, and
international levels. The SCN was an early
undertaking to share responsibility among a
number of agencies. It also incorporated the
essential component of non-governmental actors
similar to the present UN reform. Those are the
initiatives that are now carried forward with open
contact with the rest of the world, including the
business community and civil society— not only
our institutions talking together internally. And
certainly, in this context, the WHO has a key role
to play. The Sub-Committee on Nutrition and the
ACC itself symbolise the cross-sectoral approach
and the inter-agency cooperation that are
absolutely necessary to address the global
involvement of science, the public and private
sectors and the whole of civil society are key in
this area as in other vital areas for human
progress. At the national level we need open
dialogue. We have experienced that in many
countries, and we need a broad process to
create positive change. Developing clear policy
guidelines and securing practical implications are
key to success. But the same holds true at the
global level. It is not only at the national level that
you need to have serious dialogue between the
different institutions to avoid overlapping of
mandates and duplication of effort.
I want to end by referring to this picture. The
Secretary-General of the United Nations, drawing
upon the whole UN family of agencies and
institutions, needs to promote an integrated,
unified approach to global issues and this indeed
is his ambition for UN reform. To succeed, he
and his colleagues will need the support of the
world of science, of concerned citizens, of a
broad range of governmental and nongovernmental actors working together. All the
discussions— �this is my table and not your
table’— have lead to a lot of wasted effort. We
have to speak openly and directly and look each
other in the eye around the table, as if the
Secretary-General was the Prime Minister or
president and his cabinet ministers were the
leaders of agencies. He should be able to ask
each and every one of us to answer his
questions about how the mandates of UN
agencies are like one integrated approach, with
no overlap and no duplication. There is only one
audience— the people of the world, the nations of
the world, the populations of the world— not the
mandates of single organisations. If they don’t fit
together today because they were made at
different times, then we have to rearrange them.
We have to discuss how we avoid this tendency
of overlap and, of course, have the discussion
with the whole of civil society, understanding how
we cooperate, how we are coherent in our
message and how we work together for the
common goal. Without that kind of thinking, we
will continue losing efficiency and not reaching
the goals that have been set by the big
international conferences or the goals set by
each separate agency. I think we have a great
challenge. You have a lot of experience on how
that needs to be done.
Philip James has spoken to me about what we
can do to improve implementation and to
improve practical results on the ground. Well,
the test is on the ground at the country level
where people live, and if the international
institutions all go together to support a countryoriented integrated approach at that level, then
we can succeed in supporting what governments
decide. But we can never get away from building
on the political decision making in each country
and then supporting what they want. Of course,
if we have vulnerable groups and the violation of
human rights, we have to speak out to
Chapter 4: Address by Dr Gro Harlem Brundtland
governments and to the world about issues that
are not being taken care of according to basic
guidelines for human rights. Thank you for your
Richard Jolly (SCN Chairman): Thank you very
much, Dr Brundtland, for covering such a wide
range of important issues for the SCN, and for
focusing them so well at many different levels of
implementation. From your own experience, what
do you think are the two or three critical steps to
get across to a Prime Minister concerning how
she or he could mobilise more attention to
Dr Brundtland: You have to put nutrition into the
context of health and education. Without
nutrition, you don’t have the ability to learn and to
become a productive and active human being.
Coupled with that are not only the humanitarian
concerns but also the economic consequences
for any country, any population, of not having the
building blocks from the start in young children.
You have to put it into the context of economic
and social development, not only on a
humanitarian basis, because we can see that this
is not always sufficient for all political leaders
who are under strain of many different pressures.
They need to have a clear argument about why it
is also a good idea from a economic point of
Aileen Robertson (WHO): Based on your
personal past experience in environmental
issues, do you see a means by which nutrition
can be more firmly placed on the political agenda
through environmental movements? Is there an
opportunity for the health sector to work closer
on environmental issues and with environmental
Dr Brundtland: The answer is yes, and that is
why I also referred to the Rio Conference. The
links between health, nutrition, and the grass
roots level, even looking at it environmentally
with regard to agricultural patterns and food
security, are clear. There is a lot to be said in
this common concern from an environmental and
health point of view, which is also already part of
the WHO programme today. I think that
generally the answer is �yes’because you cannot
take care of nature and the environment without
being concerned about people. That is the key
message in our common future— environment
and development, concern for choices, and the
ability for future generations and not only for
present generations, to have their rights,
possibilities and opportunities.
So this
generational perspective requires us to look at
the environmental aspects also, going further
than considering only the children of today.
Judy McGuire (World Bank): At the beginning of
your speech you cited a number of international
conferences: the World Food Conference of
1973, the World Summit for Children, the
International Conference on Nutrition, and the
World Food Summit. All of these conferences
have set goals to reduce malnutrition by half in
ten or twenty years. Twenty years is far too long
for any political or even economic planning, and I
wondered what your thoughts are on shortening
the duration of our goals or changing our
perspective on how we get the UN system
moving. The UN system is 50 years old. The
right to food was set out at its outset as you
pointed out. We still have not fulfilled that goal.
We have had major changes, both in the
Secretary-General and in the three major UN
organisations concerned with nutrition— UNICEF,
FAO and now WHO— and I wondered what your
thoughts are on getting the UN system moving in
the short-term, not 20 years hence, but now.
Dr Brundtland: I think one of the problems is that
the UN system is an inter-governmental system;
an inter-country system. When we say �test on
the ground’ it means that you have to measure
what has happened in each country with all the
different goals that have been set, not by the UN,
but by the countries who sit together in the
conference hall signing a common document.
We have to monitor and survey what is
happening on the ground in each part of the
world, in close cooperation with civil society and
governments. The international organisations
become a source of setting common goals and a
source of giving support, stimulus, and debate
about results. We have to be more aware of
what I am saying because sometimes I listen to
people talking as if we, at a kind of philosophical
global level, have set goals. Then the UN
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Secretary-General or one of the leaders of the
institutions are asked why they have not reached
the goal, as if it were a personal goal for the one
person sitting at that time at the head of the
agency. No, the goals have to be made by
humanity and they have to be achieved using
democracy. Moving democracy, putting requests
to governments and political leaders, and
working at the national level and at the local level
to implement. But I agree with you, one should
have shorter targets and shorter time frames. If
the time frames are too long, the existing people
in every position will never have to answer to
why nothing has happened, and that relates to
the country level and to all our different agencies.
While I mentioned the conferences that have
specifically talked about goals in nutrition and
malnutrition, some of the other conferences that I
mentioned may be even more important. If we
don’t reach the goals set by the Cairo, Beijing
and Rio Conferences— which are even more
fundamental in many ways— you will never be
able to pursue and implement the goals set by
the food conferences without getting into focus
education, health systems, development and
reaching women and children at the local level.
How can you change habits of everything from
cooking and energy use to eating habits if you
don’t have a system to do it and to help do it?
We are in it together. That is why I speak about
the Secretary-General and his cabinet. Also in
the cabinet is the leader of the World Bank, the
IMF, and the WHO, all of them around the table
trying to look at what goals also can be
abbreviated. What are the common goals for a
broader agenda of agencies? It is easier to set
shorter-term goals if we focus.
Judy McGuire (World Bank): When we look at
the Third Report on the World Nutrition Situation,
we see very little nutrition improvement, and the
improvement we do see would have come
anyway from economic development. When we
list the commitments we have made, I think we
have failed. Based on your experience with the
Rio Conference on the Environment, what can
we learn here? What have you learned from
your own experience on how to move from words
to action?
Dr Brundtland: It is my experience that this is due
to the sectorisation of political decision making
and public opinion making. The people who are
active, who go to meetings and conferences
where commitments and resolutions are made,
stretch their imagination about what they can
sign, what they can say, and what they can hope
for. It is not the same as a political programme in
a specific country that can be checked point-bypoint after several years. General resolutions
and commitments cross country lines, and the
person who signs these resolutions is usually not
responsible for the implementation. It is not my
suggestion that we stop making resolutions or
having conferences and discussing the issues,
because then public opinion, which puts pressure
on the political decision-makers, would be even
less. I think we have to live with this kind of
tension in order to move, at least at some pace.
When you say that much of what we have
discussed as targeted approaches in the area of
nutrition has not been the main reason for
change, and that it is economic development that
has resulted in most of the change, you may be
right. But I have no doubt that the scientific work,
the advocacy work, and all the sectoral work that
have been done also have made a difference. I
am not one of those who give up. To give you
one example, I remember leading the Norwegian
delegation at a conference in 1976. When I
came to the conference hall on the first morning,
there were a number of journalists asking me
One question made a deep
impression on me— �does this meeting have any
meaning— will it make a difference?’ Already this
showed a basic cynicism towards international
work. Such cynicism is understandable, but it
will never move the world ahead. So I answered
as a young minister �even if this conference does
not make a major difference, I am convinced that
the work that has been going on in different
countries to prepare for this conference, has
moved some important issues higher up the
consciousness of many people— including
decision-makers’. This was 22 years ago, and I
still feel the same way.
I have tried to move and focus by being more
direct in my discussion with government leaders.
If the cabinet does not take seriously what the
foreign ministry is giving as instructions to the
Chapter 4: Address by Dr Gro Harlem Brundtland
different delegations, and if they agree to more
than what they are willing or ready to do, then
they should modify what they say.
inconsistency between the big declarations and
what is happening on-the-ground is undermining
the credibility of political work and democratic
decision making. We have to try to bring these
things together, not by lowering to the lowest
denominator, but by speaking about targets for a
shorter-time span, and differentiating between
the philosophical, long-term, value-based goals
and the goals that are related to on-the-ground
systematic implementation.
In any political programme, you have the
principle guidelines and value-base of a party.
These are discussed and debated and they focus
on long-term visions.
Then you have a
programme for a 4- or 5-year period saying what
the party intends to carry through within that time
frame. It then becomes more concrete. So, we
should not mix principles with more practical,
short-term goals to the extent that I feel is being
done— both at the country level, and at the
international level.
I mentioned that the Hot Springs declaration was
one page with 7 paragraphs. They were mostly
basic guidelines, but they were based on a
discussion and analysis that they felt was
practically possible to carry through, I think,
within a 5- to 10-year timeframe. You can see
that the people who wrote it thought that it was
possible. Out of the points they made, those that
we have not been able to achieve are the
economic policy points of income creation,
income distribution, public concern and state
efficiency. It is not enough to privatise, and
discuss competitive economies and other things
that have dominated the last 10-15 years.
Although many of these things are very
important, without a determined, strong,
government that takes care of common
concerns, you cannot do what the people in Hot
Springs said. In order to have a sufficiently
strong government, there is a necessity for
democracy with a strong civil society making it
effective and making the choices.
Decision-makers have to be met within
countries— at the country level, or at regional
conferences. We must reach them with the
necessary information and imagination to move
them to rethink some of their allocation. It’s a
vast work, and all of you here are needed to
make it possible.
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Chapter 5: The Global Nutrition Challenge in the Millennium
Chapter 5
The Global Nutrition Challenge
in the Millennium:
Presentation of the Draft Commission Report
Philip James
The Commission on Nutrition Challenges in the
21st Century was established by the ACC/SCN in
Kathmandu in March 1997. Its purpose is to
consider how best to meet the nutritional
challenges of the 21st century and to consider the
role that the UN can play in meeting these
challenges, taking into account the goals and
commitments established at the major
international conferences of the 1990s. This
paper presents the preliminary findings of the
Commission as set out in the draft report �Ending
Malnutrition by 2020: an Agenda for Change in
the Millennium’(1998).
With the exception of Richard Jolly (SCN
Chairman) and Ricardo Uauy (Chairman of the
Advisory Group on Nutrition), the members of the
Commission are completely independent of the
SCN process (see Box 1). This independence
has both advantages and disadvantages. The
main advantage is that the Commission
members perceive it as their job to speak their
minds. However, there are disadvantages in that
they may be preaching to the converted, and
they may also be engaging in issues that the
SCN has already considered in detail.
The Commission is taking a new perspective to
address the persisting problem of malnutrition,
and is attempting to identify whether there are
other, previously unconsidered dimensions to the
global nutritional problem that need to be taken
into account. This paper will not therefore
consider the huge problems of iodine deficiency
disorders, vitamin A deficiencies, and iron
deficiency anaemia, as these are already being
addressed. The ACC/SCN Working Group
meetings on micronutrient deficiencies (Oslo,
1998), suggest that real progress is being made
in combating iodine deficiency, that progress in
combating vitamin A deficiency is accelerating,
but that very little progress is being made in the
area of iron deficiency.
Box 1: Members of the Commission on Nutrition Challenges in the 21st Century
Philip James, Director, Rowett Research Institute, Aberdeen, Scotland
Mahbub ul Haq, President, Human Development Centre, Islamabad, Pakistan1
Kaare Norum, Director and Professor, Institute for Nutrition Research, Oslo, Norway
M.S. Swaminathan, Chairman, M.S. Swaminathan Research Foundation, Chennai, India
Suttilak Smitasiri, Head, Division of Communication and Behavioural Science, Institute of Nutrition at
Mahidol University, Nakhn Pathom, Thailand
Julia Tagwireyi, Director, Nutrition Department, Ministry of Health, Harare, Zimbabwe
Ricardo Uauy, Director and Professor, Institute of Nutrition and Food Technology, University of Chile,
Santiago, Chile
Richard Jolly, Chairman, ACC/SCN, Special Advisor to the Administrator, UNDP, New York, USA
Mahbub ul Haq died on July 16, 1998
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Malnutrition in Young Children
Globally, over 150 million children are
underweight. The distribution of underweight
children by region shows that the dominant
problem occurs in South Asia (Figure 1). This
contrasts with the long-held view that SubSaharan Africa is the major crisis region of the
world and perhaps reflects the way in which
nutritionists often associate the nature of the
problems in South Asia as being part of normal
society, without recognising the presence of a
vast endemic problem that needs to be tackled.
Figure 1: Total numbers (millions) of underweight children (under 5 years old) by region, 1995
South America
Middle America and
Near East North Africa
C h in a
South East Asia
Sub-Saharan Africa
South Asia
Source: ACC/SCN (1996)
Furthermore, a current definition of undernutrition
tends to underestimate its true impact within
populations because the definition is based on
specifying only those at the extremes of
underweight, with those classified as being
malnourished falling below the lowest limit
(-2 SD) of the reference population. In practice,
the whole population tends to exhibit a �shift’ so
that the majority of a country’s children may have
sub-optimal growth (Figure 2).
Figure 2: The hidden impact of undernutrition
Undernutrition: the hidden impact
The normal range of
childhood growth
+2.0 S.D.
N. Africa
Very High
+1.5 S.D.
Sub-Saharan Africa
S. Asia
for Age
have above
-1.5 S.D.
14% at risk
Very Low
-2.0 S.D.
Classified as malnourished
NOTE: Those classified as malnourished
fall below the lowest limit (-2.0 S.D.) of normal growth. In
practice the whole population tends to shift down in growth rates so the majority of a country's children may
have sub-optimal growth even with modest numbers formally classified as malnourished.
Chapter 5: The Global Nutrition Challenge in the Millennium
Substantial progress has been made in reducing
stunting in all regions of the world except SubSaharan Africa (ACC/SCN, 1997). However,
recent simulations by IFPRI / IMPACT projecting
progress to the year 2020 suggest that continued
progress, over what is quite a substantial period
of time, will only be modest (Figure 3). The
nutrition community has not confronted this
problem in a coherent way, and it is now time to
rethink the basis on which we set out analyses
and plan action.
Figure 3: Projecting progress in reducing underweight in children
Source: Pinstrup-Andersen et al. (1997)
Maternal Nutrition
In some communities, the basis for malnutrition
starts before birth, with mothers of low body
mass index (BMI) on average giving birth to
babies of low birth weight (Shetty and James,
1994). Although this direct relationship between
maternal weight and birth weight is not a new
finding, the nutritional state of women, both
before pregnancy and during pregnancy, is
something that should be given more emphasis,
especially by major policy makers.
The amount of weight gain required by a woman
during pregnancy in order to ensure giving birth
to a child with normal birth weight, is set out in
maternal nutrition criteria described by WHO
(1995). In spite of this, there is as yet no system
in society where the requirements of antenatal
care, even in a crude way, are locked into the
pre-existing weight and rate of weight gain of the
mother during pregnancy.
Studies in South Africa and elsewhere during the
1960s and 1970s have demonstrated quite
profound effects of supplementary folic acid in
dramatically reducing the likelihood of low birth
weight (for example, Baumslag et al., 1970). In a
recent review of trials evaluating different
prenatal interventions to prevent or treat impaired
foetal growth (de Onis et al., 1998), folate, zinc,
and magnesium supplementation during
pregnancy were shown to have possible
supplementation shown to be beneficial (Table
1). On the basis of these analyses, we need to
look at antenatal care in a completely new way in
order to avoid the huge handicap that arises from
low birth weight.
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Table 1: Nutrition interventions to prevent
intrauterine growth retardation
Beneficial effect
Protein/energy supplement
Possible beneficial effect
Number of
Source: de Onis et al. (1998)
Focusing on women, a study carried out in ten
states of India has shown that half the adult
female population in rural areas is malnourished.
Other studies in India have shown chronic
energy deficiency in nearly 70% of women (Table
2). In Asia, similar levels are seen in Bangladesh
and Pakistan. There are 30-40% malnourished
women in Viet Nam. In Africa, the figure varies
between 20 and 40% depending upon whether
there has been a catastrophe, war, famine or
Table 2: Chronic energy deficiency in India
in the late 1980s
10 States
Hyderabad village
IFPRI rural village
EC rural pool
III (%)
II (%)
I (%)
Source: NIN (1989-90)
The consequences of adult malnutrition extend
beyond those of maternal risk of underweight
babies. The ability of women to sustain work and
their sheer physical capacity to cope are
markedly dependent upon their body mass.
Illness and handicap, in terms of sickness, days
off work, days sick in bed and death rates, all
increase with increasing malnutrition (Shetty and
James, 1994). We are therefore dealing with a
new dimension of malnutrition, which so far has
not been incorporated into our thinking.
Malnutrition in women, with its links to low birth
weight, inability to sustain work, and reduced
capacity to care for the family, is an area that we
have not taken on board at all.
The Agricultural Dimension
In addressing the agricultural dimension of
malnutrition, the Commission has taken the
population of India to give an example of the
current lack of food provision. Approximately
1800 calories of food is supplied per person in
India. If, however, India were a society in which
people could grow to an appropriate height by
virtue of being well fed during childhood, in which
people were not wasted, and in which people
were able to engage in all the activities that they
desired, then a third more food per person would
be needed (Figure 4).
Not only is there a fundamental challenge for the
provision of food, but there are also the
considerable problems and risks associated with
the fact that, globally, we have come to rely on
amazingly few types of food crops (Mann, 1997).
We are becoming increasingly dependent on the
mono culture, single system of agriculture with all
the implications in terms of intensive production.
Many neglected and under-utilised crops,
currently referred to as �coarse cereals’, have
highly desirable nutritional profiles and should
therefore be redesignated as �nutritious cereals’.
In considering how best to ensure nutritional
diversity, or �global nutrition security’, in addition
to the number of calories produced from a crop,
an eight-point strategy has been developed as
an important long-term insurance policy for
agriculture (see Box 2).
A new approach of measuring and comparing
weights and heights of both children and mothers
has been developed in order to prioritise village,
regional and national policies for combating
malnutrition (James et al., 1999). Figure 5
shows a schematic representation of this new
approach. If mothers are thin, they may simply
not have enough food. It is not surprising
therefore that thin mothers are associated with
thin children, as the problem is a fundamental
problem of food security and household provision
of food on a daily basis. But the model also
illustrates other scenarios. Adequately fed
mothers may have thin, malnourished children,
and this raises a number of issues in relation to
UNICEF’s concern for caring.
Chapter 5: The Global Nutrition Challenge in the Millennium
Figure 4: Projected food needs of the Indian population
Source: IDECG (1992)
Figure 5: A new approach to prioritising village, regional and national policies
BMI <18.5
< -2Z
Weight for
Height Z
Public health
measures &
maternal education:
household food
Low priority
> -2Z
Source: James et al. (1999)
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Box 2: Global nutrition security (Swaminathan, 1998)
Re-focus national priorities in agricultural research to allow for crop diversity as well as the intensity of production
Recreate the demand and market for a wide range of crops
Develop processed foods based on a mixture of nutritious crops
Include minor crops in national food security measures
Redesignate �coarse cereals’as �nutritious cereals’in order to alter the image of such micronutrient rich crops in
public perception
Promote conservation of a wide range of food crops
Promote breeding efforts designed to increase the micronutrient content of crops like rice, wheat and maize
Promote mixed cropping and multiple cropping sequences which provide space in the cropping system for underutilised but nutritionally desirable crops
The world today sees a society where foods are
transported in enormous amounts on a daily
basis across the globe to feed the affluent. The
human food chain is rapidly being transformed
into a global market with developed countries
intent on providing their populations with a huge
variety of foods at ever-lower prices and
irrespective of seasonal availability.
however, has huge implications for food safety—
how can food safety be assured? In addition, as
the global free trade opens up, how can farmers
in the developing world compete effectively with
Western industries already bolstered by
decades-long subsidies?
Seasonal Deprivation
Seasonal fluctuations in the annual provision of
food can have significant effects on adult and
infant malnutrition. Analyses reveal that weight
changes of adults alter in response to seasonal
shortages of food, and that these food shortages
are induced by complex interactions of climate
and soil (Ferro-Luzzi et al., 1994). Recent
studies in The Gambia have shown that
seasonally-induced adult body weight changes
are linked to low birth weight, a greater
propensity for neonatal death, childhood stunting,
anaemia and the risk of permanent brain
impairment. These effects on children born
during and after seasonal deprivation can,
however, be combated by food supplements:
supplementation of pregnant women during the
hungry season has been shown to result in a
substantial shift in birth weight and a marked
reduction in the proportion of children with low
birth weight (Ceesay et al., 1997). This seasonal
impact of deprivation currently affects millions of
women of normal body weight and is additional
to the 200 million malnourished women of
reproductive age.
Seasonal deprivation also has profound longterm implications. Comparison of adult survival
curves in The Gambia for those born in the
harvest season and those born in the hungry
season shows a remarkable effect due to season
of birth (Figure 6). The premature deaths of
those born during the hungry season are due
both to increases in deaths from infections and to
increases in deaths during childbirth. The
implications are that if seasonal deprivation were
eliminated overnight, the burden of physical
survival and reproductive capacity would still
remain for another 50 years.
In a similar way, by comparing blood glucose
levels in adults born at different times during the
second world war Dutch famine, Ravelli and
colleagues (1998) have recently shown that
foetal nutritional deprivation leads to high
susceptibility to diabetes in later life. We are
therefore programming a health budget 40 years
hence if we continue to neglect maternal
Mental and Cognitive Development of
Studies by Sally Grantham-McGregor and her
colleagues in Jamaica (1991) show the
remarkable effect of different treatments for
stunted children on development quotient (Figure
7). Supplementation with food markedly
improves the development quotient. An even
more remarkable finding is that in the absence of
supplementation, the provision of stimulus and
care— encouraging the children to interact with
society and explore their environment— results in
a greater improvement in development quotient.
When supplementation and care are combined,
children essentially catch up with non-stunted
children in their development quotient.
Chapter 5: The Global Nutrition Challenge in the Millennium
Furthermore, evidence is now emerging to
suggest that children who have received
maternal care, interaction and nurturing during
early childhood have a higher intellectual ability
in secondary school.
Figure 6: Survival curves according to season of birth in rural Gambia
Percentage surviving
Born in harvest season
Born in hungry season
Age in years
Source: Moore et al. (1997)
Figure 7: Development quotient of stunted children treated differently
Development quotient
Supplemented and
6 mo
12 mo
18 mo
24 mo
Age in months
Source: Grantham-McGregor et al. (1991)
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
New Dietary Challenges: Chronic Diseases
Diet-related chronic diseases not only afflict
affluent society, but are now also the scourge of
the developing world. In numerical terms,
diseases of the circulatory system and cancers
are greater in the developing world than in the
developed world (Figure 8). Cancer is enhanced
by overweight, and Figure 9 shows the high
proportion of overweight people in some
developing countries. An extraordinary transition
is occurring— from the malnutrition of India, to the
huge problems of chronic disease in Colombia,
for example. There is a global pandemic of
obesity (WHO, 1998). In the Pacific Islands, for
example, three quarters of adults are clinically
obese and half are diabetic (Table 3).
Figure 8: Causes of death in the developed and developing world, 1996
Developed world
(including economies in transition)
Developing world
(including least developed countries)
(151) 1.2
(5,522) 45.6
Infectious &
parasitic diseases
43.0 (17,161)
Diseases of the
circulatory system
24.5 (9,778)
(2,544) 21.0
Diseases of the
respiratory system
(979) 8.1
(3) 0
9.1 (3,629)
1.5 (582)
Maternal causes
Other and unknown
(2,798) 23.1
4.8 (1,909)
Perinatal and
neonatal causes
(119) 1.0
9.5 (3,802)
7.7 (3,063)
Figures in bold are percentages and figures in brackets refer to the number of deaths in thousands.
Source: WHO (1997)
Table 3: The epidemic of obesity in Asia and the Pacific
Western Samoa— whites
Western Samoa— blacks
Age group
Prevalence of Obesity (%)
0.5 (mixed)
Source: WHO Collaborating Centre, Rowett Research Institute, Scotland
Chapter 5: The Global Nutrition Challenge in the Millennium
Figure 9: BMI distributions in adult populations (male and female)
Costa Rica
BMI Classes
% population
Source: WHO (1995)
In looking where the problem of heart disease is
most prevalent, the ex-USSR, Czech Republic,
and Hungary come top of the league table (1992
figures) according to the Cardiovascular
Epidemiological Unit (1994). Undoubtedly, this is
primarily caused by environmental and dietary
factors. In Norway, a decrease in death rates
due to coronary heart disease in the 1980s was
preceded by a progressive reduction in total and
saturated fat intake and with an increase in
polyunsaturated fat consumption. The situation in
Norway during this century demonstrates that
with a coherent public health strategy, and not
simply adult education and individual behavioural
management, the course of coronary heart
disease can be changed.
One of the effects of dietary change is illustrated
in Figure 10, which shows that as the fat content
of the diet in Denmark increased from 1935 to
1985, so did the prevalence of obesity in 18year-old recruits. In Brazil, middle-aged women
are the first group in the population to become
overweight— indeed, in almost every part of the
world, women are more obese than men. Not
only therefore are women handicapped in the
rural under-privileged part of society by
underweight, but as soon as one sees a shift in
dietary patterns and physical activity, women are
again handicapped.
The current regional estimates of diabetes will
undoubtedly escalate over the next few years
diverting health resources unless a new
approach to addressing this problem is found
(WHO, 1997).
Areas for Action and Ways Forward
In order to devise coherent strategies, priorities
for action need to be set to reduce maternal
malnutrition, low body weight, numbers of
stunted children and all the issues related to dietrelated chronic disease (Box 3). Furthermore,
the priorities need to be set in relation to the
magnitude of the problem and the level of
population risk. This approach has been applied
to the major micronutrient deficiencies, where
four levels of population risk have been selected
(Table 4).
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Figure 10: Secular trends in dietary fat and the prevalence of obesity in Danish army recruits
Prevalence of BMI > 31
% dietary fat
Prevalence / 1000
Dietary fat consumption (energy %)
Source: Lissner and Heitmann (1995)
Box 3: Areas for action
Micronutrients: Vitamin A, Iron, Iodine
Maternal nutrition: avoidance of low birth weight
Adult malnutrition: household security
Obesity: maternal nutrition; physical activity; diet with major intersectoral policies
Cardiovascular disease: major dietary policies in addition to consumer education
Cancers: major reappraisal of horticultural needs, farming, transport and refrigeration policies for increased
vegetable and fruit consumption especially in urban areas.
Table 4: Prevalence of subclinical deficiency by level of population risk
Level of population risk
IV (severe deficiency)
III (moderate to severe deficiency)
II (mild and widespread deficiency)
I (mild and clustered deficiency)
Subclinical signs of deficiency (%)
Vitamin A
=80 - 100
=50 - <80
=10 - <20
=50 - <99
=30 - <50
=2 - <10
=20 - <50
Source: IOM (1998)
We have a dilemma. We need targets, but we
also need to go to countries. But how do we go
to countries and capture the imagination of
political leaders and financiers, whilst at the
same time, have a discerning plan involving
interagency cooperation? This is where we are
rather inept in the way in which we put across
our proposals.
If we are going to develop a global compact (see
Box 4), we will need to take on a completely new
approach, recognising that if we are going to take
on some of the major global challenges, we have
a whole array of conditions to account for. We
have to be far more flexible, coherent, policydriven and action-motivated than we ever have
been in the past. We need to prioritise, but need
Chapter 5: The Global Nutrition Challenge in the Millennium
to be coherent, integrative and effective in order
to combat this array of challenges.
Box 4:
A new global compact for nutrition
1.Formulate a Social Compact
в—Љ Prime Ministers / Presidents
в—Љ People representatives
в—Љ UN agencies / World Bank / IMF
в—Љ Bilaterals
2. End childhood malnutrition by 2020
3. Develop national regional views of principal
4. Implement locally developed action plans with
coherent inter-agency collaboration with
subsidiarity of decision making.
5. Use nutritional wellbeing as a critical marker
during financial readjustments
ACC/SCN (1996) Update on the Nutrition
Situation 1996: Summary of Results for the
Third Report on the World Nutrition Situation.
ACC/SCN, Geneva.
ACC/SCN (1997) Third Report on the World
Nutrition Situation. ACC/SCN, Geneva.
ACC/SCN (1998) Working Group Reports from
the ACC/SCN 25th Session, Oslo, Norway, 28
March 1998. ACC/SCN, Geneva.
Baumslag N, Edelstein T, Metz J (1970)
Reduction of incidence of prematurity by folic
acid supplementation in pregnancy. British
Medical Journal 1:16-17.
Commission on Nutrition Challenges in the 21 st
Century (1998) Ending Malnutrition by 2020: An
Agenda for Change in the Millennium. Draft.
ACC/SCN, Geneva.
de Onis M, Villar J, GГјlmezoglu M (1998)
Nutritional interventions to prevent intrauterine
growth retardation: evidence from randomised
controlled trials. European Journal of Clinical
Nutrition 52 Suppl 1:S83-S93.
Ferro-Luzzi A, Branca F, Pastore G (1994) Body
mass index defines the risk of seasonal energy
stress in the Third World. European Journal of
Clinical Nutrition 48 Suppl 3:S165-S178.
Grantham-McGregor SM, Powell CA, Walker SP,
Himes JH (1991) Nutritional supplementation,
development of stunted children: the Jamaican
Study. Lancet 338:1-5.
Consultancy Group) (1992) The Functional
Significance of Low Body Mass Index. James
WPT and Ralph A (eds). Proceedings of an
IDECG workshop. IDECG, Rome.
IOM (Institute of Medicine) (1998) Prevention of
Micronutrient Deficiencies. Howsen CP, Kennedy
ET, Horwitz A (eds). National Academy Press,
Washington, DC.
James WPT, Ferro-Luzzi A, Sette S, MascieTaylor CGN (1999) The potential use of maternal
size in priority setting when combating childhood
malnutrition. European Journal of Clinical
Nutrition. (in press)
Cardiovascular Epidemiology Unit (1994)
Myocardial infarction and coronary deaths in the
World Health Organization Monica Project:
registration procedures, event rates, and casefatality rates in 38 populations from 21 countries
in four continents. Circulation 90:583-612.
Lissner L and Heitmann BL (1995) Dietary fat
and obesity: evidence from epidemiology.
European Journal of Clinical Nutrition 49:79-90.
Ceesay SM, Prentice AM, Cole TJ, Foord F,
Weaver LT, Poskitt EME, Whitehead RG (1997)
Effects on birth weight and perinatal mortality of
maternal dietary supplements in rural Gambia: 5year randomised controlled trial. British Medical
Journal 315:786-790.
Moore SE, Cole TJ, Poskitt EM, Sonko BJ,
Whitehead RG, McGregor IA, Prentice AM
(1997) Season of birth predicts mortality in rural
Gambia. Nature 388:434.
Mann C (1997) Reseeding the green revolution.
Science 277:1038-43.
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
NIN (National Institute of Nutrition, India) (Annual
Report 1989-90) Body Mass Index and Mortality
Rates: A 10-Year Retrospective Study. NIN,
Pinstrup-Andersen P, Pandya-Lorch R,
Rosegrant MW (1997) The World Food
Situation: Recent Developments, Emerging
Issues, and Long-term Prospects. 2020 Vision
Food Policy Report. IFPRI, Washington, DC.
Ravelli ACJ, van der Meulen JHP, Michels RPJ,
Osmond C, Barker DJP, Hales CN, Bleker OP
(1998) Glucose tolerance in adults after prenatal
exposure to famine. Lancet 351:173-177.
Shetty PS and James WPT (1994) Body Mass
Index: A Measure of Chronic Energy Deficiency
in Adults. Food and Nutrition Paper No.56. FAO,
Swaminathan MS (1998) Strengthening Food
Security at the Level of the Individual by
Widening the Food Basket. Paper prepared for
the Commission on Nutrition Challenges in the
21st Century. ACC/SCN, Geneva.
WHO (1995) Physical Status: The Use and
Interpretation of Anthropometry. Technical
Report Series No. 854. WHO, Geneva.
WHO (1997) World Health Report. WHO,
WHO (1998) Obesity— Preventing and Managing
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Consultation on Obesity, 3-5 June 1997. WHO,
Tim Frankenberger (CARE): In any sustainable
development activity it is important to not only
have civil society and government working
together, but also the private sector. What is
your perspective on the private sector in this
Ricardo Uauy (Commission): The report that has
just been presented is a conceptual framework.
The action side is only just starting, and this is
one of the stages of the action side. Parallel to
this technical report there will be two levels of
activities. One that will involve high-level political
leaders and community leaders who would
influence the decision-making process—
including the private sector, and one that will be
linked to the human rights approach. In this
aspect, the Commission has contacted highprofile leaders like Mary Robinson. We are at
first creating a consensus that is based on the
technical side. This is a process that hopefully
will continue in the months ahead, enrolling the
contribution and the reaction of political leaders,
social leaders, of community leaders, of business
leadership around the world. The process is only
in a first draft stage.
Rainer Gross (GTZ): I appreciate very much that
the obesity factor has been taken up. All the
surveys in Latin America suggest that obesity is
not just an aspect of women but it is an aspect of
poor women. Similar patterns are also seen in
South-East Asia, and particularly in the country
where I am working— Indonesia.
I would
conclude therefore that not only undernutrition,
but also overnutrition, is a problem of the whole
society, and not just a problem of individuals. I
would like to refer you to an excellent recent
overview in Scientific American, which presented
some exciting news on the biochemical insights
regarding the interaction between stress and
obesity. We are learning a lot about this issue
and I think we have to address the problem in
relation to poverty. What I miss in the report, is
the interaction between environmental pollution
and nutrition. With the new wave of chronic or
non-communicable diseases, in particular in
developing countries, we have to address this
Philip James (Commission): I agree. We are
beginning to have tremendous concern about the
environmental problems in, for example, Central
Roger Shrimpton (UNICEF): I would like to give a
UNICEF response to the Commission’s report.
Firstly, I would like to say that UNICEF sees the
fulfilment of the right to good nutrition as the
principal challenge to the United Nations system
for the new century. This is the central message
of the State of the World’s Children 1998, and a
long-held agency position. We, therefore,
Chapter 5: The Global Nutrition Challenge in the Millennium
welcome the creation of the Commission and the
charge given to it by the SCN and its member
agencies. We now welcome the Commission’s
report, which is a thought-provoking reflection on
the complex and compelling problem. It is all to
the good that a distinguished panel of scholars
and practitioners share with the international
community, through the SCN, the visionary ideas
and recommendations embodied in the report.
Discussion of the report is also in the spirit of
improving on this draft as a guide for interagency
collaboration to advance the fulfilment of nutrition
rights. We hope that the report will be an
important tool in keeping nutrition as a high
priority for all agencies, even amidst competing
priorities and in the challenging environment of
UN reform. UNICEF welcomes in particular the
suggested focus for action on the reduction of
stunting through the central strategies of
reduction of low birth weight, and improved infant
feeding. Recognising maternal care as the key
to combating stunting in the next generation
highlights the connectedness of nutrition actions
through the life cycle. Maternal care for nutrition
is a neglected element of policy and
programmes, even as the recognition of the
importance of birth weight and nutrition in very
early child development has increased. In the
constructive spirit, we would like to point out four
aspects of the report that we think could be
strengthened, making it even more useful for all
of our agencies.
The first one is related to historical underpinning.
We feel that the report could be stronger if it
better reflected the recent history of consensus
building that the SCN agencies have been
through, both in the SCN and in the International
Conference of Nutrition of 1992. The principles
in the ICN declaration are still relevant, and the
process by which they were reached should not
be minimised. Furthermore, the extensive
exercise conducted by the ACC/SCN to
understand how nutrition has improved by
drawing lessons from real experience in several
countries was also an important consensusbuilding exercise. These lessons learned,
presented in the SCN document How Nutrition
Improves, also represent a consensus on a
number of factors that should figure in any
discussion of strategies. Among these is the
importance of the status of women, which should
be embodied in all nutrition-related action and
advocacy. Advocacy in favour of governments
spending on basic social services and
mobilisation of communities are also parts of
those elements. Structuring the report more
closely on the range of lessons already
articulated in the SCN documents would have
provided some continuity to this analytical base.
The second issue is around the nature of the
malnutrition problem. One aspect of the
consensus captured in the ICN was about the
nature of the problem of malnutrition and its
causes. In particular, it was agreed at the ICN
that care for nutrition in households, particularly
care of women and young children, was treated
on a par with household access to adequate food
and to health services and a healthy environment
as determinants of malnutrition. The ICN
background paper on care for nutrition explained
clearly the phenomenon by which child
malnutrition exists, even in the face of adequate
health services, sanitation, and household food
security. These ideas are no less relevant today
than in 1992. The Commission report is weak in
its consideration of the elements of care for
nutrition as well as for links to food security and
The third issue is about the centrality of rights.
As the Secretary-General has noted
categorically, all activities of the United Nations
must be based on, and reflect, a human rights
approach. The report would be stronger and
more credible as a UN document were human
rights more central to this analysis and
recommendations. To call for a new social
contract for nutrition for example, ignores the
well-established body of human rights
instruments that form the basis for the work of
the United Nations and already constitutes a
social contract for nutrition. The report would do
well to call for a strengthening of the focus on
nutrition in the existing processes by which
States Parties report on their human rights
obligations to the relevant United Nations bodies.
There is great scope for making nutritional
concerns more pronounced in this reporting and
the SCN, as well as member agencies, have a
clear role to play in this regard.
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
The fourth issue is around the scope of priorities
for nutrition problems. There is no question that
non-communicable chronic diseases related to
nutrition and other factors are a growing problem,
both in developing and industrialised worlds.
There is also convincing evidence that reducing
low birth weight and undernutrition in its many
forms in the early months of a child’s life reduces
that child’s risk of suffering from a number of
chronic diseases in adulthood. UNICEF believes
that this should be a principal strategy for the
SCN agencies to address the problems of
chronic diseases in adulthood as it is consistent
with a wide range of other objectives, including
reduction of stunting. Approaches that aim first
at the problems of undernutrition more directly
associated with poverty, disenfranchisement and
poor access to resources and basic services at
the household level are necessarily those that
should be of most concern to our central
agencies and to the SCN.
The fifth and last item concerns follow-up
processes. UNICEF appreciates the report’s
conclusion that regional strategies are necessary
and useful to combat malnutrition. Nonetheless,
regional nutrition strategies already exist in many
cases, although we agree they can be
strengthened. Existing regional meetings should
be used to articulate and advocate the agenda of
the Commission report, but a new series of
regional meetings would be burdensome for
government partners who have already
participated in the formulation of regional
agendas related to nutrition. We hope that our
constructive consideration of the report, together
as SCN member agencies, will result in a
common commitment to some key principles and
actions that will move forward the fight against
global malnutrition.
Mike Golden (University of Aberdeen and ACF):
The startling data that has just been presented
shows how devastating stunting and wasting
are— in both children and adults— and how the
legacy of past failures is building up for the
future. The data have all been observational and
epidemiological. Philip James has shown us that
we are in a terrible state, but he has not shown
us what we can, or should, do about it. In 1982,
George Beaton reviewed supplementary feeding
programmes— over 200 of them. On reading that
report and looking at the original papers, it is
quite clear that the supplemental feeding
programmes were universally unsuccessful.
Looking at the programmes that have occurred
since 1982, which I have reviewed, the
supplemental feeding programmes have, by and
large, also been unsuccessful. We still have the
problems of stunting and wasting and we don't
have a successful strategy to implement, we
don't know what to do about the problem or, in
biological and physiological terms, why the
problem occurs.
I would like to ask the Commission whether they
have considered the underpinning science— the
causation of stunting; the causation of thinness in
adults; the causation of low birth weight. Has the
Commission come across any successful
programmes at all? I am reminded of data
published by Michael Gracy on Australian
Aboriginals, which described four decades of
nutritional surveys, showing that the nutritional
state today is no different than it was four
decades ago. During that time, public health
measures were put in, children were vaccinated,
and there were social security and food security.
But these have had zero effect on the weight and
the height of the Aboriginal populations. Clearly
the strategies that we have had in the past have
been failures. So why do we persist with the
same strategies? I suggest this is because we
need to do something because of the magnitude
of the problem, but we do not know what else to
We can talk about addressing these problems,
and we can all see that we have a major
problem, but I do not see that we know what to
do about them. I do not see that there has been
an investment in nutritional science to
understand the causation of stunting, of low birth
weight or of thinness in adults, so that we can
formulate reasonable strategies based on
It is axiomatic that we cannot apply what we do
not know!
Ricardo Uauy (Commission): There is always
room for more science. The Commission feels
that the body of science that has emerged over
the last 15 years at least allows us to move
Chapter 5: The Global Nutrition Challenge in the Millennium
forward. In the Third Report on the World
Nutrition Situation you will find that science has
made an impact in programmes, and that
progress is being made. The missing link to
strengthen action is not the need for more
science— we will always need more science— but
the need to apply the science that we know and
the science that is emerging. At present, the
bottleneck is in the application of science at the
programme level, especially at national level.
Successful pilot projects around the world have
demonstrated that we can advance. We don’t
have all of the answers, but at this point I think
there is enough knowledge to put into action,
while at the same time, we generate new
knowledge. Hopefully, by putting this knowledge
to work we will learn how to make these
programmes more effective. So your point is
well taken. But at present, the call is for action in
terms of reducing stunting. If you look at the
progress, many of the countries around the world
are making dramatic progress at improving
stunting with an integrated approach where the
three components of the agencies are present—
care, food security, and health.
Basil Hetzel (ICCIDD): My comment is related to
our experience in meeting the gap between
available knowledge and its application, which
has just been alluded to by the panel. I offer this
experience as being relevant to other problems.
How has the progress with iodine deficiency
disorders been achieved? I submit that it has
been achieved, first of all, as a result of the level
of scientific knowledge. This permits the
available technology to be applied, and the
understanding of the problem as a major cause
of brain damage (considered by WHO as the
major preventable cause of brain damage in the
world today), to be widely accepted. The second
step was the establishment of an international
NGO, which I have the honour of chairing.
George Beaton made the comment in his
�history’ that the establishment of this NGO in
relation to the SCN was indeed a critical step.
That NGO has been able to work in the UN
system in advocacy. It has been able to reach
countries. It has developed various strategies at
the global, regional, and country levels. The
remarkable progress that we have seen has
resulted from collaboration between agencies in
the UN system, the multilateral agencies, the
bilateral agencies, the NGOs, the private industry
(the salt industry) and finally, the world service
club, the Kiwanis who have raised US$ 25 million
towards the campaign so far. I offer the model of
the International Council for Control of Iodine
Deficiency Disorders (ICCIDD) as one where
there has been the establishment of a global
partnership. That global partnership has brought
about a very dramatic improvement in the
situation and control of iodine deficiency as a
cause of brain damage in the last decade. I
believe this model deserves consideration by the
Commission and by the SCN in relation to other
Tom Marchione (USAID): I look forward to taking
the Commission results back to the Bureau for
Humanitarian Response in Washington, which is
in charge of an US$ 800 million food assistance
programme where food supplementation plays a
large part. In response to Michael Golden’s
comments, if one looks at the SCN publication
How Nutrition Improves, indeed you will see that
there are examples where one can have an
impact on child malnutrition through
programmatic approaches. However, I would
also like to support his view that there be an
emphasis on programming and how to do it. We
have set a goal of reducing general malnutrition
by one half and I think we have to focus on how
we go about achieving that goal, if not by the
year 2000, then shortly after that.
Philip James (Commission): Concerning Mike
Golden’s issue, i.e., trying to create a substantive
body of knowledge and a capacity within
developing countries, we have actually been
discussing that here in Oslo with the IUNS.
There is a real need for us to go from our near
colonialist approach where we essentially, dare I
suggest it, seduce the most able in developing
countries into UN or NGO organisations. We are
very troubled by the need to nurture a
powerhouse of intellectual analysis and
independent national thought within particular
countries, and I think that we do see
programmes where we are absolutely convinced
that this is the right approach. It would be so
much better if that were done in a coherent way
with the local institutes full of their vigorous
analysis of what’s needed on a national basis. I
would very much hope that as we develop this
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
report we will see that in some way we need to
lock that process of nurturing and capacity
building, which Dr Brundtland mentioned, into the
whole mechanism by which we achieve change.
Anna Ferro-Luzzi (Italy): I enjoyed your
presentation, and the way it brought together a
whole picture. In this respect, I appreciated
particularly one aspect of it, namely the concept
that malnutrition should not be seen only as
expression of food deprivation, but also as a
consequence of unbalanced diets. As you
pointed out, this problem is not limited to
developed countries. The developing country
burden in chronic diet-related diseases such as
obesity, cancer, and ischaemic heart disease, is
already great, and is bound to increase
exponentially in the near future with an ageing
population and change in lifestyle. The problem
we face today is the difficulty of persuading
policy makers and academia in developing
countries that these aspects should be taken into
serious consideration. The same applies also to
donors— be it governments or agencies— who
are very reluctant to put chronic diet-related
diseases on their agenda. I would warmly wish
that the next draft of the report include advice on
the strategies and arguments needed to increase
the awareness on this aspect, perhaps
emphasising the economic benefits of early
prevention of chronic diseases.
Julia Tagwireyi (Commission): One of the areas
for discussion is �how to do it’. If you look at the
successful case studies that have been
developed, there is certainly a lot of information.
But we have not extended the �how to do it’ in
terms of how we sustain the political commitment
to nutrition in a way that makes it politically
expedient for the politician to support nutrition
and to make it beneficial in economic terms. It is
all very well to have well-conceived programmes
but they just remain on paper. If we don’t
manage their scarce resources, how would I, as
head of nutrition, make an argument so that my
minister of finance sees it as economically
possible or expedient to invest in nutrition? I
think the �how to do it’ in that aspect is a bit
deficient and I think that here we can learn.
There are a lot of agencies that have been past
masters at this and I think we need to harness
those experiences.
The ICCIDD is one.
UNICEF has also been quite successful in
engaging policy makers. We have to move from
science to practice. We have to engage in
political dialogue. If we do not make a coherent
enough argument for making nutrition an
investment, then we can have good science and
the best programme design, but we won’t get
very far. This is where we have to move to when
we look to the 21st century.
Judy McGuire (World Bank): What we have is a
partial analysis of the problem. We have a far
more coherent epidemiological presentation than
a presentation of the rest of the issues. It is
partial because even with the epidemiology,
which is well represented, we really don’t know
what to do about it. Take the case of low birth
weight, which is absolutely critical. There is a
very serious debate as to whether you can
intervene at all in pregnancy, whether you can
deal with adolescent girls, or whether you have
to really start with the zero to 2-year-olds and
improve their growth. It is an inter-generational
problem, so even at that level of diagnosis we
don’t have much. Also, there is no political or
economic analysis here. I would maintain that
poverty, more than anything else, is driving these
nutrition problems and I find it to be a severe
vacuum that there is no assessment of poverty
anywhere in this analysis. The agricultural
analysis does not refer to IFPRI’s 2020 Vision. I
am hoping that the whole symposium will give us
a fuller picture. Suttilak’s presentation hopefully
will focus on behavioural change. Behaviour and
care may not be covered, but behavioural
change is certainly not covered and what we are
talking about is far more than just diagnosing the
problem as an epidemiological problem.
Gro Nylander (National Hospital and the National
Coordinator of the Baby Friendly Hospital
Initiative in Norway): Thank you for summing up
some of the knowledge about the devastating
effect of malnourished mothers and their small
children. One would expect that the
malnourished mothers of these small children
would have a lower chance of lactating plentifully
and successfully. Would you care to comment
on what is the difference between children who
are given a chance of a proper catch-up weight
after birth compared to children who stay
Chapter 5: The Global Nutrition Challenge in the Millennium
Philip James (Commission): It’s quite intriguing.
In an IDECG symposium 2 or 3 years ago,
Prentice showed that the physical capacity of
mothers to keep generating milk is truly
astonishing at surprisingly low body weights. But
of course what you are then doing is requiring
that such a woman is able to substantially
increase her food intake if she is not to suffer
personally. The evidence that children can catch
up from low birth weight is true, but as I look at
the evidence, it is not as good as it should be.
What we don’t understand is whether the failure
of low birth weight children to catch up is in part a
reflection of the mother’s problems, too. There is
no doubt that the breastfeeding issue is
enormously important, but as several have
commented, we have quietly neglected some of
the big issues surrounding the weaning
processes. That is something that we ought to
certainly include. But we are clear that it would
be much better to avoid low birth weight if at all
Ricardo Uauy (Commission): I think the answer
from developing countries is very clear. Low
birth weight is associated with decreased
prevalence of breastfeeding and decreased
successful breastfeeding. It is associated with
high risk of malnutrition and there is the
potentiating effect of low birth weight on
malnutrition, stunting and both mental and
physical development. This means that you
have to consider both the mother and the infant.
The literature of developing countries is very
strong in indicating that one potentiates the
other, both in terms of physical and mental
Fernando Viteri (University of California,
Berkeley and UNU): The Commission states
institutional strengthening and building as one
aspect on how to act. It also agrees on the
importance to empower governments and
nations to take action. It is important in this
regard not only to create a governmental will to
act, but also to provide each country with a
critical mass of well-trained people who can
support, promote, and sustain action by the
government. In this regard it is important for the
UN agencies and other institutions to commit
more funding and more opportunities for training
scientists from the developing world, in nutrition
and many other related disciplines, either locally
though regional institutions or through
international cooperation. My plea is to increase
the capacity of institutions by increasing the
number of scientists so that we can create a
critical mass at the country level.
Julia Tagwireyi (Commission): The issue of
capacity is particularly relevant to Sub-Saharan
Africa. It is no secret that in terms of capacity—
programme planning, research, and so on— SubSaharan Africa is very limited. We have received
several different kinds of support over the
years— it has not been a total vacuum— but
some of that support has not been very
empowering or sustainable. Some of our besttrained Africans are outside Africa. In looking
ahead to a new vision for institutional and
capacity building, we should look at a model that
helps to keep our best people working on the
worst problems in the globe, which are in SubSaharan Africa. We need your best teams to
work on the problems we have, and I welcome
the new initiative by UNU. I know that under the
new leadership of Dr Garza we will see more
investments in Africa. We don’t have the
capacity to sustain all these very good
interventions. The numbers aren’t there to even
do some of this work. So this needs to be a
serious focus in any strategy to make an impact
on the malnutrition problems in Sub-Saharan
Ricardo Uauy (Commission): This is a very
neglected area, and I think we all share the
responsibility. People from developing countries
share the responsibility in accepting projects that
leave nothing after they are completed. It is not
enough to have teams come in and then leave
with the project, with a publication, but with
nothing on the ground. I challenge all of us to
consider what is left after our donors leave a
project. I also suggest that perhaps a levy
should be placed on each project to create a
fund for institutional development. Nobody wants
to take charge of building capacity. Everybody
wants to do his or her project. This is demanding
of very limited human and institutional resources.
The Advisory Group on Nutrition (AGN) has
looked at the issue even of training refugee
workers in Africa. At the present time they have
to be trained at the London School of Hygiene
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
and Tropical Medicine. This needs to be
reassessed and I think the IUNS initiative and the
donors should consider doing something about
this at the earliest possible time.
Elisabet Helsing (Board of Health, Norway): I feel
that the work is not quite finished and I join the
concerns expressed by Julia Tagwireyi and Anna
Ferro-Luzzi that the plans for action still have
some way to go. I am particularly concerned that
as we approach the double burden of disease we
do not start talking in two different terms of
solutions. We need to be clearer about the need
for comprehensive food and nutrition policies.
Urban Jonsson (formerly Regional Director for
UNICEF in South Asia): Both the report and the
presentation have emphasised the remarkable
difference in nutritional status between South
Asia and Sub-Saharan Africa. Someone said
that we need to have a correct diagnosis before
we can have a solution. Any report about the
global nutrition situation today will have to be
precise about the remarkable fact that in spite of
more food per capita, higher income, and many
other better things such as health services,
South Asia has a 50% higher prevalence of
malnutrition than Sub-Saharan Africa. We also
know that this is associated with a very high
prevalence of low birth weight in South Asia. My
position is that this is related to the different
forms of exploitation of women in South Asia and
Sub-Saharan Africa. Very little has been said
about the extreme importance of the
subordination, exploitation, and marginalisation
of women in societies. This will explain not only
differences between South Asia and SubSaharan Africa, but also the differences within
these continents.
I think that this reflects the need to bring down
the analysis of causes to what I call a structural,
basic level that relates to the macro-economic
and macro-political aspects. I know that this is
controversial, but I don’t think one can avoid it in
a report that attempts to describe the situation in
Flavio Valente (Global Forum on Sustainable
Food and Nutritional Security, Brazil): I would like
to see if we could move ahead with some other
issues in this discussion. I like the urgency that
the Commission puts into its report. The
decision by the World Food Summit to reduce by
half the number of malnourished by the year
2015 is understood by civil society as a very low
mark. We would like to achieve this as soon as
possible. UNICEF and ICN have already shown
the importance of treating human beings as
whole. When you do that— when you feed them,
when you give them care and health care— they
grow and they become healthy human beings.
The problem is that this has not convinced
governments. That is why civil society has
placed so much importance in the new approach
of the UN. First, in working together, and
second, the heavy emphasis on human rights.
We need to discuss bridging historical gaps and
economic gaps within society. Working with
nutrition for many years I have seen that even if
children recover from their malnourished status
when they are young, if they are then placed in a
deprived situation, they cannot recover. I think
the same is true for nations.
I would also like to ask the SCN to make an effort
to bring into the nutrition discussions some of the
international organisations that are dealing with
this from the other end, such as the World Trade
Organization. They really don’t think too much
about the impact of their policies. Perhaps if they
were here, discussing these issues with you,
they will start to see the impact of their policies.
Richard Orraca-Tetteh (University of Ghana): I
like this holistic approach to the nutrition
problems in the world and I think the suggestion
made by the ICCIDD is very interesting. To give
an example of what we did in Ghana, we saw the
iodine problem as being important in our area.
We wrote a project that the Canadian
International Development Agency (CIDA)
supported. Now we have salt iodisation in the
country. This was based upon local people
trying to get things done, and this leads to the
question of capacity building. I have been in
Ghana as a nutritionist since 1959. We do not
have the necessary support for training. We
need to look at capacity building and we need
the support to train more people from various
parts of Africa who will stay and work in Africa.
Asbjorn Eide (World Alliance for Nutrition and
Human Rights): The descriptive part of the draft
Chapter 5: The Global Nutrition Challenge in the Millennium
report is very useful. The insight, for instance, on
the question of intra-household food allocation
and the South Asian puzzle I think is very
interesting. As Urban Jonsson and others said,
the analysis of causes needs to be much deeper.
I would like to address very briefly what you have
been saying about the human rights aspects and
about the use of a social contract, a global
contract or a nutrition contract. It is very
important to take into account the existence of a
number of mechanisms— legally binding
mechanisms. For instance, the Convention on
the Rights of the Child has 191 ratifications
today— four more than the number of United
Nations members. They are legally bound to
address nutrition of the child. I am not saying
that you are reinventing the wheel, but you
should at least take that part of the system more
fully into account in your further thinking. There
is also the Convention of Elimination of
Discrimination Against Women, which is also
binding on a great number of states. The
Working Group on Nutrition, Ethics, and Human
Rights of the SCN has produced a paper that
reviews the development of human rights within
the UN. Let me finally remind you that after the
World Food Summit in 1996, there was a
mandate explicitly given to the High
Commissioner for Human Rights to take the lead
role in working with the various agencies. I know
that FAO and others are already in close
collaboration with the High Commissioner for
Human Rights, and that again is something that
you should follow with close attention. I think
that the scientific insights that you can give will
be of very great help so I look forward to future
Cutberto Garza (UNU): In answer to Julia
Tagwireyi, the United Nations University is very
much committed to capacity building, especially
in Africa. Discussions have already begun and
we hope to sit down with those of you who have
stayed in Africa, to develop a long-term plan for
capacity building in that region. We also have
plans to initiate a similar type of effort in the
newly independent states of the former Soviet
Union. We are very pleased to have your
support in this, and invite the other UN agencies,
NGOs, bilaterals, and multilaterals to help us in
this endeavour.
George Beaton: I have been associated in one
way or another with the SCN for many years. I
see the present effort as something relatively
new for the SCN and, in that regard, I
congratulate and thank you for what you did not
do. You did not offer prescriptions for action.
Instead, what you are asking the people in this
room to do is something that the SCN was
established to do but has actually done very
seldom. You have asked us, nay, challenged us,
to begin a discussion among ourselves about
what we can collectively do if we agree on the
problem. If this can happen, it may be the single
most important contribution of this Commission
as we move toward the 21 st century.
Graeme Clugston (WHO): We welcome the
report, which is very thought provoking. Your
presentation focused on science and newly
emerging issues, particularly the critical issues of
low birth weight and maternal malnutrition and
the forgotten role of adult malnutrition, stunting
and survival. May I just add two or three
Firstly, there is a global movement underway,
which has been generated by events over the
last decade such as the World Summit for
Children, the International Conference on
Nutrition and the World Food Summit. These
were very carefully planned initiatives that
identified emerging key issues and the strategies
to address them. I think the issues that the
Commission has highlighted need to be fed into
this process.
Secondly, the importance of capacity building
which many have mentioned, and which is at the
very forefront of WHO’s action, is fundamental
because sustainable and permanent reduction of
malnutrition depends on it. Capacity building
includes such things as infrastructure
strengthening, training, human resource
development, and strengthening of national
nutrition policies and strategies. It is often not
highly visible work, particularly on the
international scene, but it is crucial. The
Commission may be unaware that WHO,
UNHCR and WFP do indeed run workshops in
Africa for training people in emergency
forecasting and management.
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Thirdly, the key emerging issues should not
ignore, overlook or underplay the importance of
IDD, vitamin A deficiency or iron deficiency
anaemia, and the models that they provide for
addressing some of the other newly emerging
issues. Other key issues that I think ought to be
strengthened in the report include household
food security and caring, food safety and quality,
breastfeeding promotion, and the crucial issue of
complementary feeding.
Finally, apart from nutrition as a human right, the
report needs to wrap all this up with a greater
emphasis on nutrition and development, ensuring
that nutrition itself and its elements are included
in national development policies and poverty
eradication policies at the national level. Again, I
think this alludes to what sort of action is needed
at country level. I look forward to hearing the
other presentations and appreciate the stimulus
of both your presentation and the report. I
suggest building these things into the ongoing
framework of ICN follow-up that is already in
place, to further strengthen the momentum in
countries, regions, and globally.
Chapter 6: Nutrition Challenges and Gender in Asia
Chapter 6
Nutrition Challenges and Gender in Asia
Suttilak Smitasiri
Recall the face of the poorest and the weakest man whom you may have seen
and ask yourself if the step you contemplate is going to be of any use to him.
Will he gain anything by it?
Will it restore him to control over his own life and destiny?
In other words, will it lead to self-reliance for the hungry
and spiritually starving millions?
Then you will find your doubts and yourself melting away.
— Mahatama Gandhi—
Over the last fifty years, science has contributed a
tremendous knowledge on nutrition. Most nutrition
problems are known today in terms of what are the
etiological factors, referring particularly to
immediate causes, and why they are so important.
This is indisputably a proud achievement for
nutrition scientists of this century. Nonetheless, as
the close of this millennium is coming near, many
remain perplexed by the fact that this vast body of
knowledge has not been helpful enough for poor
people. Malnutrition can still be found in almost
every country in the world. Furthermore, it has
recently been reported that even with progress,
prospects for reducing malnutrition among the
world's children are grim (UNICEF, 1997). This is
indeed a challenge for all nutrition workers in the
next millennium.
This paper presents the view of a female nutrition
practitioner— who works in an Asian developing
country— on the nutrition situation in Asia and how
to approach the problem more effectively in the
future. A Thai experience in rapid reduction of
malnutrition among young children is discussed.
The issue of gender is critical to the success of
empowering individuals (women and men), families
and communities in taking positive actions towards
nutritional improvement.
Nutrition in Asia: The Challenges
The Asian region consists of a few high-income
countries such as Japan, Singapore, and South
Korea, while most countries in East, Central, and
South Asia have low- to middle-income economies.
Estimates of trends in childhood stunting in the
region show some improvement (ACC/SCN,
1997), with the most rapid rate of progress
occurring in South-East Asia (at –0.9 percentage
points per year), followed by South Asia (at –0.84
percentage points per year), compared with the
estimated trend across all regions (at –0.54
percentage points per year). Nevertheless, the
current Asian economic crisis will, to a certain
extent, be an obstacle to this development.
As for childhood malnutrition (underweight), it is
estimated that more than 40% of children under
the age of five are malnourished in most countries
in South Asia and a few countries in South-East
Asia, i.e., Viet Nam, Laos, and Indonesia
(ACC/SCN, 1996). Myanmar, Cambodia, Bhutan,
Sri Lanka, Maldives, and the Philippines have
around 30-39% malnourished children; Malaysia is
reported to have 20-29%; while China, Mongolia,
and Thailand reportedly have between 10-19%.
No data are available for North Korea (World Bank
Group, 1997), however, recent international media
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
do indicate a severe malnutrition problem among
young children in this country.
More than 80% of pregnant women in India and
Bhutan are anaemic. In Nepal, Indonesia,
Myanmar, Thailand, Malaysia, Bangladesh,
Vietnam, and China, over 50% of pregnant
women are anaemic (see Table 5). In many
Asian countries where prevalence of anaemia is
likely to be high, data are not available. In
addition, 45% to 60% of women of childbearing
age in South-East and South Asia are
underweight. As a consequence, there are
millions of low birth weight babies born each year
(ACC/SCN, 1997).
Thus, the malnutrition
problem is perpetuated from one generation to
the next in Asia.
Over the past decade, progressive country efforts
have been recognised; for example, the distribution
of iodised salt as a means to combat iodine
deficiency disorders. In many Asian countries, well
over a half of households consume iodised salt
(UNICEF, 1997). Vitamin A interventions have
also been implemented; however, it is estimated
that around two million people still suffer from
clinical vitamin A deficiency and as many as 34
million are currently weakened by sub-clinical
vitamin A deficiency in the region (IVACG, 1998).
Table 5: Anaemia during pregnancy in Asia,
most recent data available (1985-95)
Sri Lanka
% pregnant women
with anaemia
Source: World Bank Group (1997)
Overall, there has been a significant advance in
nutritional development in Asia for the last twenty
years. In the future, however, it is clear that
innovative actions will be needed to save lives and
improve nutrition of so many mothers and children
in this area, since malnutrition contributes to over
half of deaths among underfives in developing
countries (UNICEF, 1997). Moreover, as the Asian
population forms the greatest proportion of the
world’s population (see Figure 11), what would
happen to global sustainable development if Asian
mothers and children remain malnourished?
Indeed, it is a challenge for all nutrition workers and
supporters within the region and at the international
level to collectively search for better ways and
means to improve the situation.
What’s Next?
"Everyone says nutrition is important but no one
does anything about it". This paradoxical saying
has often been heard over the last ten years. Is
nutrition losing its own identity? Does nutrition no
longer have a role in human development? As
mentioned earlier, I believe one great contribution
of this century is the fact that knowledge is now
available to solve almost all undernutrition.
Moreover, it is convincingly clear now why
investing more in nutritional improvement is a
sound idea (see Table 10, page 74). Nutrition in
the next century should therefore have a new
image; it should be an important subject that
everyone should not only talk about, but should
proactively address. Decisions are yet to be made.
To make a difference, nutrition workers must
collectively provide more evidence that such an
investment would be rewarding.
Nutrition Development in Thailand: Lessons
Good news for future nutrition work is the fact that
through the hard work of so many people, there
are several unique examples of successful nutrition
interventions in almost every part of the world.
Thailand is one of them. Thailand has been
recognised by the nutrition community for its ability
to eliminate severe and moderate malnutrition
among children under five years of age, and
reduce overall malnutrition from 51% to 19% in
only one decade. What were the essential
elements in this successful intervention?
Chapter 6: Nutrition Challenges and Gender in Asia
From a macro perspective, it can be said that the
contribution to Thailand's nutrition success in the
last two decades is due to policies and
programmes that were created to reduce both
poverty and malnutrition. Important elements
included targeting poor areas, focused
interventions, a primary health care structure that
promoted community participation in planning,
implementation and evaluation in community
health development. There was also a strong
emphasis on nutrition in rural income generation
schemes and integrated small farming systems
(Winichagoon et al., 1992).
observed from
1990 to
to 2050,
Note : Based on United Nations projections
From a practical perspective, there are at least two
main elements in this change process. Firstly, it is
important to understand that Thailand has a head
of the state— the King and his family, who have
been working continuously to promote rural
sustainable development in this country for over
fifty years. This has created a good environment
for all development work including nutrition.
Secondly, there has been a strong and committed
group working for nutrition. Grounded with a
primary health care philosophy, a good technical
background and strong management skills, a
group of academics and practitioners from
multisectors formed a core group for nutritional
development in Thailand more than twenty years
ago. Importantly, one of the members later
became the leader behind the successful primary
health care movement. Some of them are still
active today.
Because of the nature of this group, a strong
commitment from many sectors for nutrition
improvement became possible. Together, they
provided strategic policies, participatory action
plans for both macro and micro levels, as well as
systematic monitoring processes.
importantly, these leaders acted individually and
collectively to alert the public about nutrition
problems and their burden for the nation's future.
These leaders, from the very beginning, realised
that nutrition is not only a human disease but a
societal problem that can only be improved by
collaborative efforts.
Grounded with a primary health care
philosophy, a good technical
background and strong management
skills, a group of academics and
practitioners from multisectors
formed a core group for nutritional
development in Thailand more than
twenty years ago. This body
helped merge nutrition work into
the national poverty alleviation plan…
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
implementation, and monitoring of community
Also, these change-masters were keen to involve
more people from the economic, agricultural, public
health, education, social development, and
research sectors as well as to include training in
problem identification and planning. Concrete
information was used for deciding upon priority
problems, identifying goals and target groups, and
for selecting appropriate actions. Professional,
technical, and resource support were arranged on
a continuous basis with adequacy of coverage
manageable by the system. Furthermore, their
initiation for the national planning authority to
facilitate the planning process, to coordinate and to
monitor food and nutrition policies in line with
development policies was crucial for success. This
body helped merge nutrition work into the national
poverty alleviation plan which targeted high poverty
concentration areas through the national
committee to communities in the 1980s. Under
this plan, nutrition activities, primary health care,
food for family consumption, and other basic social
services were integrated in the target villages.
At least ten women and men spent their spare time
working as volunteers to help improve nutrition and
health in each rural Thai community. Information
was provided to enable them to take action. This
information-action loop has proved helpful for
generating more participation needed to solve
nutrition problems at the community level.
Political concerns, public opinion, and awareness
of nutrition problems, as well as success stories,
have been created strategically through several
communication media, by credible leaders and
decision makers, administrators at various levels,
and the public in general. Effective policy
communication, the use of the innovative
information-education-communication approach, a
continuous investment in capacity building at all
levels and last, but not least, various kinds of
support from international communities have been
essential to good progress in nutrition in Thailand
(see Figure 12).
In my opinion, this mass-scale operation for
nutritional improvement in Thailand was possible
because both planning and implementation
strategies were based on holistic, multisectoral
concepts, and on self-reliance. Community
participation through primary health care, village
financing systems, and basic minimum needs or
quality of life indicators were key to the design,
Group i.e.
volunteer etc.
Figure 12: Thailand holistic health and nutrition development process
Fund from
Political will, commitment and support from national and international levels
Chapter 6: Nutrition Challenges and Gender in Asia
A Practical Approach to Effective Nutrition
Actions in Asia
To improve nutrition actions in Asia, the search for
remedies requires critical attention and the right
thinking. The need for nutrition workers to realise
that the causes of malnutrition are complex,
context-oriented, and dynamic in nature has
already been mentioned (Pinstrup-Andersen,
1991). A new way of thinking and doing the work
now needs to be considered.
Indeed, there is more than one unique way to
look at malnutrition in a society. What remains
important, however, is the decision to agree upon
principles. Table 6 shows the importance of
different ways of seeing the world and trying to
understand it. If the underlying reality is
perceived differently, objectives, planning
approaches and implementation will also be very
Thailand's experience seems to
indicate somehow a mixture of modernism and
post-modernism. However, post-modern thinking
has probably created more changes when the
total experience is examined carefully.
Table 6: Modern and post-modern
currents in development
Simple, uniform
with macro
with micro
Role culture
Task culture
Adapted from Maxwell (1996)
A recent attempt to look into the issue of gender
differences in nutrition and health revealed that
more than anywhere else in the world, girls have
poorer health and nutrition than boys in Asia (Kurz
and Johnson-Welch, 1997). These findings seem
to confirm the common saying that the male
population is superior in Asian culture. Traditionally
and currently, the Asian family still, in most cases,
prefers a male child. However, the degree varies
between countries and between different
communities within a country.
Within Asia, data are indicative of the especially
poor condition of maternal nutrition in South Asia.
The shortage of private income, fewer
opportunities for women to participate in the market
economy, poor access to health services, and low
female literacy, as well as the treatment of women
(an aspect of its culture), are important in shaping
the nutritional status of this population. More
understanding about women will be helpful to
improve nutrition (Osmani, 1997).
As it is defined, gender refers to the qualitative and
interdependent character of women’s and men's
positions in society.
Gender relations are
constituted in terms of the relations of power and
dominance that structure the life chances of
women and men. Gender divisions constitute an
aspect of the wider social division of labour that is
rooted in the conditions of production and
reproduction, and reinforced by the cultural,
religious and ideological systems prevailing in a
society (Ostergaard, 1992).
Gender issues are thus very important not only for
nutrition but for all aspects of human relations.
More understanding into these issues would
definitely be valuable for human development as a
whole. Nevertheless, gender, like nutrition, is a
very complex and sensitive issue. But it is
important not to let this complexity detract from
action. Therefore, it is proposed that nutrition
workers realise the importance of gender issues as
related to nutrition and take a practical approach in
utilising this new understanding.
From a
practitioner's view, taking a gender perspective to
nutrition development is to better understand the
needs and priorities of both women and men. This
understanding can then be used to influence both
genders to work together towards successful
nutritional improvement (which reduces gender
disparities and promotes equality) at family,
community, national and international levels.
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
In Thailand, the Institute of Nutrition at Mahidol
University has been working with both women and
men at various levels to improve micronutrient
nutrition in the Northeast of the country for the last
ten years. Our experience shows that both
genders can work together to improve nutrition,
and the poor can take an active part in nutritional
development. We have learned that it is necessary
to start where the poor can make a difference.
Knowledge is important but it should lead to
solutions that are relevant to the lives of the poor.
Therefore, it is important not only to understand
nutrition problems but also the cultural realities of
men’s and women’s lives, as well as their ways of
thinking about the situation.
Participatory techniques, for example, the
Appreciation-Influence-Control (A-I-C) Approach
(Smith and Landais, 1991) and the Communitybased Nutrition Monitoring (CBNM) problemsolving model (Pelletier et al., 1994), should be
used to create more participation among all
stakeholders in planning, implementation, and
control of the intervention. Provided with adequate
information and good facilitation processes through
social marketing and implementation (Smitasiri,
1994), the poor can be key players for their own
nutritional development.
My understanding about the South Asian situation
regarding nutrition implementation, when
compared to Thailand, marks at least three
important differences:
1) South Asia faces more difficulties in terms of
food production and living standards;
2) South Asia has a much wider economic and
social gap between those who have and those
who have not;
3) the role of ordinary women in society in South
Asia is more limited.
Two-thirds of adult women in South Asia are
reportedly illiterate. Seventy-four million women
are �missing’— the unfortunate victims of social
and economic neglect. Even with several female
Prime Ministers in the region, the situation has
only slightly improved (ul Haq, 1997). Physical
and psychological suffering, as well as the lack of
opportunities in education and income generation
among poor women of South Asia, are well
Generally, both belief and religious practice in this
region create a condition where �sons are
important’. Parents without a son cannot enter into
heaven. A woman therefore has a responsibility to
get married and produce male children. As an
individual, her parents will take care of her when
she is young. Once married, her husband will do
so and when she becomes old, a son will take the
responsibility. A woman thus cannot survive
without a support from a husband and a son. This
is one reason she needs to take better care of
Moreover, according to religious teachings, a
woman should not be trusted with a decision, be it
big or small (Kabilsingh, 1992). This has been a
belief and practice for more than 2000 years in this
area. It has changed to a certain extent in the
upper classes, but not among the less advantaged
population. Despite these known difficulties,
lessons learned from successful food and nutrition
interventions in this area indicate that active
participation by women is critical (Quisumbing et
al., 1996).
In my view, ordinary Thai women are not very
different from other Asian women. A good Thai
woman is called �Mae Sri Reaun’which means a
�good lady of the house’. However, equal
opportunity for free basic education has made an
impact on the development of the female
population in Thailand. For example, the Thai
Government Statistical Office reported that
around 70% of Thai women were considered
employers, government employees, private
employees or own account workers since the
1980s. Thai women today are engaged more
and more in social activities and employment.
Furthermore, Buddhism, practised by most Thai
people, though originating in India more than
2000 years ago, says that both men and women
have an equal potential to understand the
Buddha’s teachings. Also, most Thai husbands
are proud to leave decisions regarding
household management, including family food
and nutrition, to their wives. This often includes
money to be used in the family. With access to
appropriate information, Thai women therefore
are decisive in nutritional matters. Because of
this background, women are key actors for
nutrition in Thailand.
Chapter 6: Nutrition Challenges and Gender in Asia
Gender-sensitive nutrition action is important for all
Asian countries and it is especially significant for
those in South Asia. Systematic and concerted
efforts are needed to create a critical mass of
leaders— especially women leaders— who can
understand the importance of this approach at
various levels. Realistic goals and interventions
should be grounded with the level of support that
can be mobilised nationally and internationally for
change. And, the work must be manageable by
the system during and after the initial interventions.
Jawaharlal Nehru once said,
Good nutritional science should be combined with
good knowledge of the intervention context.
Assessments need to be done not only for nutrition
and health of populations, but also for any potential
for change that already exists or can be
strengthened within the target communities— be
they large or small— and for any windows of sociocultural opportunities, which could be built upon for
nutritional improvement. In addition, good multidisciplinary team work will be necessary in order to
cope with the complexity of the food and nutrition
Thus, even with the sense of urgency to reduce
malnutrition in Asia, it is very important not to bring
in nutrition work that dis-empowers poor people
rather than empowers them.
Nutrition work needs to be integrative especially
where the process of female empowerment is
already in progress. More knowledge will be
needed about the integration process. However,
action need not be delayed. An information-action
loop or experiential learning process has proven
helpful in successful interventions. In other words,
a nutrition intervention should start where
communities have a potential for change by aiming
to create more examples and to generate more
changes through community and social learning.
Final Notes
Malnutrition problems in Asia require immediate
and concerted efforts.
Nevertheless, wellcalculated action is crucial. I believe that the Thai
experience, which has evolved for over two
decades due to the commitment and participation
of people at various levels, can be considered by
other Asian countries. Holistic and processoriented development requires a lot of effort at the
start but it can produce sustainable changes in the
long run.
”Strong winds are blowing all over Asia.
Let us not be afraid of them, but
rather welcome them for only
with their help can we build
the new Asia of our dreams.
Let us have faith in these great
new forces and the dream
which is taking shape.
Let us, above all, have faith in the
human spirit which Asia has symbolised
for those long ages past".
The balance between process and outcome
indicators in determining the success of nutrition
implementation is important and needs further
discussion. Nutrition workers in the future should
aim at significant and long-lasting changes by
proactively learning from the people—
communicating and working with them, both
women and men, to do something appropriate to
improve nutrition. Action should be based on
sound knowledge, and knowledge must be
grounded in the reality of the people. The role of
international agencies as good facilitators and
catalysts for this direction in the areas of
implementation, research, and training is
fundamental to minimise the usual time lag
between thinking and practice.
The author would like to express sincere
appreciation to Charrotte Johnson-Welch and
Kathleen Kurz of the International Center for
Research on Women (ICRW), Washington, DC, for
their constant support. Working with ICRW, I have
learned more about women and nutrition. Also, my
heartfelt appreciation and respect go to all women
leaders and people in Northeast Thailand who
taught me to be practical through their committed
belief and untiring efforts for nutrition and health
improvement in their communities.
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
ACC/SCN (1996) Update on the Nutrition Situation
1996: Summary of Results for the Third Report on
the World Nutrition Situation. ACC/SCN, Geneva.
ACC/SCN (1997) The Third Report on the World
Nutrition Situation. ACC/SCN, Geneva.
IVACG (1998) Sustainable Control of Vitamin A
Assessment, Surveillance, and Evaluation. Report
of the XVIII International Vitamin A Consultative
Group Meeting, Cairo, Egypt, 22-26 September
1997. IVACG, Washington, DC.
Kabilsingh C (1992) Women in Buddhism. In:
Women Study. Kabilsingh C. (In Thai) Thammasat
University, Bangkok.
Kurz K and Johnson-Welch C (1997) Gender Bias
in Health Care Among Children 0-5 Years:
Opportunities for Child Survival Programs. A
Review Paper Prepared for the BASICS Project.
Published for the USAID by the Basic Support for
Institutionalizing Child Survival (BASICS) Project,
Arlington, VA.
Maxwell S (1996) Food security: a post-modern
perspective. Food Policy 21:155-170.
Osmani SR (1997) Poverty and Nutrition in South
Asia. ACC/SCN Text of the Abraham Horwitz
Lecture delivered at the ACC/SCN Session in
Kathmandu, 17-18 March 1997. ACC/SCN,
Ostergaard L (1992) Gender. In: Gender and
Development: A Practical Guide. L Ostergaard
(ed). Routledge, NY.
Pelletier DL, Morris MF, Kraak V (1994) The
CBNM Problem-Solving Model: An Approach for
Improving Nutrition-Relevant Decision-Making in
the Community. A manual prepared for the CBNM
Strategy Workshop. Cornell University, Ithaca, NY.
Pinstrup-Andersen P (1991) Targeted nutrition
interventions. Food and Nutrition Bulletin 13:161169.
Quisumbing AR, Brown LR, Feldstein HS, Haddad
L, Pena C (1996) Women: the key to food
security. Food and Nutrition Bulletin 17:79-81.
Smitasiri S (1994) Nutri-Action Analysis: Going
Beyond Good People and Adequate Resources.
Mahidol University, Salaya, Thailand.
Smith WE and Landais FL (1991) A new approach
to organizing and planning. Development Southern
Africa 8:233-238.
ul Haq M (1997) Human Development in South
Asia 1997. Oxford University Press and the Human
Development Centre, New York.
UNICEF (1997) The State of the World's Children.
Oxford University Press, New York.
Winichagoon P, Kachondham Y, Attig GA (eds)
(1992) Integrating Food and Nutrition into
Development: Thailand's Experiences and Future
Visions. Mahidol University, Salaya, Thailand.
World Bank Group (1997) Sector Strategy: Health,
Nutrition, and Population. The World Bank,
Washington, DC.
Urban Jonsson (UNICEF): There are hardly any
similarities between Thailand and South Asia. In
South Asia, millions of women are missing,
infanticide is common, and the population
pyramid is continuing to change. Certain districts
in Thailand have an unbelievable balance
between men and women. The situation for
women in South Asia is quite different from that
in Sub-Saharan Africa. In Sub-Saharan Africa
women are primarily the mothers of their
husband’s children. In South Asia, a married
woman is a commodity, owned by her husband
and his family.
In Sub-Saharan Africa,
traditionally, infertility is the only legitimate
reason for divorce. In South Asia, infidelity is the
only legitimate reason.
Ruth Oniango (AGN): On both continents,
women are marginalised and oppressed. In
some local languages in Sub-Saharan Africa, a
woman is not a person. The international donor
Chapter 6: Nutrition Challenges and Gender in Asia
community has assisted and instilled confidence
in women, and has made men realise that
without women, they are nothing.
communities are made up of men, women,
children, livestock, and everything in it. It is
better to include men, and to sensitise them,
because then they support the women and they
work together. It is important to include both
genders in projects. In Africa, at the political
level, you can find a whole commission made up
of women, discussing women’s issues. Of
course this never goes anywhere. In contrast, a
commission that discusses economic issues
doesn’t have a single woman on it. We need to
understand the environment within which we are
operating. We also need to instill confidence in
women. If you go and sit in a women’s group and
there are one or two men present, the women
will not stand up and discuss their issues. They
let the men do the talking. It has been instilled
into women for so many years that firstly, they
have no idea what they can contribute, secondly,
that they have no business standing up to talk in
front of men, and thirdly, that their business is to
produce, serve men, and sit down. Instilling
confidence, and at the higher level, leadership
and training are very important.
Suttilak Smitasiri: In preparing for this
presentation, I asked my Bangladeshi, Indian,
and Pakistani colleagues at Mahidol for input.
They said that even in India, there is a big
difference between one state and another. In
one part of India, females have even more power
than men. We need to look at the problem in a
way in which we can take action. There are so
many NGOs and organisations that already work
to empower women. When we think about
nutrition we think about a problem. For example,
if we are interested in vitamin A, we search for
the problem and then we try different ways to
solve it, but we never think about the potential for
change. In South Asia, we need to start from
what we have already. The difficulties for women
to talk in South Asia are much greater than for
women in my country.
I spoke with a
Bangladeshi NGO that has been very effective in
working at the community level and asked �how
do you learn this? Do you know what the women
think?’ The man said that you don’t have to
know what women think to be effective, you only
have to know how to get into the system to be
able to provide them with something. To
understand would be very difficult. I challenged
him to go back and do it, but he said �what is
more important is that you have to work with the
men to be able to get to the women’. So this is
very critical. Even though we have to work with
women to make a difference, we should not
create more conflict within her family.
Lilian Marovatsanga (AGN): I am from Africa and
have visited several Asian countries. One of the
similarities between Africa and South Asia is the
empowerment of women. Successful projects
have incorporated this into their strategy.
Urban Jonsson (UNICEF): Women both in Africa
and in South Asia are exploited— they are subordinated. But there are 34 million women
missing in South Asia. The form of exploitation is
totally different.
Mohamed Abdulla (UNESCO): I come from the
South of India— Kerala State. Some years ago a
group from Boston arrived and compared the
status of women in Kerala with the women in
Boston. The only difference they could find was
in GNP— nothing else. The Kerala situation has
shown that it is possible through proper
education and proper training to overcome some
of the health and nutritional problems. The UN
has repeatedly said that we should follow the
Kerallian model to make progress in developing
Rita Bhatia (UNHCR): I would like to compliment
my colleague from South India. One of the
commitments of the Kerala project came from the
community and the community leaders. It was
very interesting to see your opening slide with a
quote from Mahatama Gandhi and your closing
slide with a quote from Jawaharlal Nehru— I was
very proud to see those names— both men.
That in itself shows that there is a need for
political will and commitment. In Kerala, the
literacy rates are very high. It comes back to
what Dr Brundtland said earlier— you cannot
improve nutrition without education.
The continent is so heterogeneous that you
cannot generalise. To add to what Urban
Jonsson said— the woman is a commodity to her
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
husband. She is not a wife— she belongs to the
family. In rural India, the head of the family is the
mother-in-law. In Africa, women can choose
their husband, but in Asia this still does not
happen. It’s a marriage of not one man and one
woman, but a marriage of families. One has to
keep in mind the social values and context while
you are trying to bring in some changes to
improve the nutritional status and health of the
Chapter 7: Achieving the 2020 Vision, with Special Reference to Gender Issues
Chapter 7
Achieving the 2020 Vision,
with Special Reference to Gender Issues
Per Pinstrup-Andersen and Rajul Pandya-Lorch
Much is known about the action required to
assure a food-secure world. A great deal of
thought and effort have been expended to
identify priority action at the individual,
household, community, national, regional, and
global levels. Most recently, at the World Food
Summit convened by the FAO in November
1996, leaders from around the world signed the
Rome Declaration on World Food Security,
reaffirming �the right of every person to have
access to safe and nutritious food, consistent
with the right to adequate food and the
fundamental right of everyone to be free from
hunger (FAO 1996).’ They pledged their political
will and their common and national commitment
to achieving food security for all and to an
ongoing effort to eradicate hunger in all
countries, with an immediate view to reducing the
number of undernourished people to half the
present level no later than 2015. Toward this
end, they made seven commitments and agreed
on a comprehensive plan of action (FAO, 1996).
The International Food Policy Research
Institute's (IFPRI) �2020 Vision for Food,
Agriculture, and the Environment’ is a world
where every person has access to sufficient food
to sustain a healthy and productive life, where
malnutrition is absent, and where food originates
from efficient, effective, and low-cost food
systems that are compatible with sustainable use
of natural resources (IFPRI, 1995). Sustained
action is required in six priority areas to realise
the 2020 Vision:
Strengthen the capacity of developingcountry governments to perform appropriate
Enhance the productivity, health, and nutrition of low-income people and increase their
access to employment and productive
Strengthen agricultural research and extension systems in and for developing
Promote sustainable agricultural intensification and sound management of natural
resources, with increased emphasis on
areas with agricultural potential, fragile soils,
limited rainfall, and widespread poverty;
Develop efficient, effective, and low-cost
agricultural input and output markets;
Expand international cooperation and
assistance and improve its efficiency and
The first priority area of action is to selectively
strengthen the capacity of developing-country
governments to perform appropriate functions,
such as maintaining law and order, establishing
and enforcing property rights, promoting and
assuring private-sector competition in markets,
and maintaining appropriate macroeconomic
environments. Predictability, transparency, and
continuity in policymaking and enforcement must
be assured. The efforts of the past decade to
weaken developing-country governments must
be turned around. More effective local and
national governments are essential for other
partners, such as individuals, households,
communities, NGOs, and the private sector, to
contribute to food security. Governments must
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
also be helped to relinquish those functions that
are better performed by others such as NGOs.
Governments should facilitate food security for all
households and individuals, not by physically
delivering needed foods to all citizens but by
facilitating a social and economic environment
that provides all citizens with the opportunity to
assure their food security.
The second priority area of action is to invest
more in poor people in order to enhance their
productivity, health, and nutrition and to increase
their access to remunerative employment and
productive assets.
Governments, local communities, and NGOs
should assure access to and support for a
complete primary education for all children, with
immediate emphasis on enhancing access by
female and rural children; assure access to
primary health care, including reproductive health
services, for all people; improve access to clean
water and sanitation services; provide training for
skill development in adults; and strengthen and
enforce legislation and provide incentives for
empowerment of women to gain gender equality.
Improved access by the rural poor, especially
women, to productive resources can be facilitated through land reform and sound property
rights legislation, strengthened credit and
savings institutions, more effective rural labour
markets, and infrastructure for small-scale enterprises. Social safety nets for the rural poor are
urgently needed. Direct transfer programmes,
including programmes for poverty relief, food
security, and nutrition intervention, are needed in
many countries at least in the short-term and
must be better targeted to the poor.
Efforts must be made to lower fertility rates and
slow population increases. Strategies to reduce
population growth rates include providing full
access to reproductive health services to meet
unmet demand for contraception; eliminating risk
factors that promote high fertility, such as high
rates of infant mortality or lack of security for
women who are dependent on their children for
support because they lack access to income,
credit, or assets; and providing young women
with education. Female education is among the
most important investments for assuring food
The third priority area of action is to accelerate
agricultural productivity by strengthening
agricultural research and extension systems in
and for developing countries. Agriculture is the
life-blood of the economy in most developing
countries; it provides up to three-quarters of all
employment and half of all incomes. There are
very strong links between agricultural productivity
increases and broad-based economic growth in
the rest of the economy. Research from Africa
and Asia shows that for each dollar generated in
agriculture, a dollar to a dollar and a half are
generated in other areas of the economy (Hazell
and Röell, 1983; Delgado et al., 1995).
Agriculture has long been neglected in many
developing countries, resulting in stagnant
economies and widespread hunger and poverty.
Yet, there is considerable evidence, particularly
from East Asia, that rapid economic growth is
facilitated by a vibrant and healthy agricultural
sector (World Bank, 1993). The key role of the
agriculture sector in meeting food needs and
fostering broad-based economic growth and
development must be recognised and exploited.
To make this happen, agricultural research
systems must be mobilised to develop improved
agricultural technologies, and extension systems
must be strengthened to disseminate improved
Efforts must be made to lower fertility
rates and slow population increases.
While expanded agricultural research is urgently
needed for all ecoregions, added emphasis
should be placed on sustainable productivity
increasers in areas with significant agricultural
potential but with fragile soils, low or irregular
rainfall, and widespread poverty and natural
resource degradation.
Interaction between
public-sector agricultural research systems,
farmers, private-sector companies that conduct
agricultural research, private-sector enterprises
in food processing and distribution, and NGOs
should be strengthened to assure relevance of
research and appropriate distribution of
Investments in strategic
international and regional agricultural research
with large potential international benefits should
be expanded to better support national efforts.
Chapter 7: Achieving the 2020 Vision, with Special Reference to Gender Issues
Biotechnology research in national and
international research systems should be
expanded to support sustainable intensification
of small-scale agriculture in developing countries.
Effective partnerships between developingcountry research systems, international research
institutions, and private- and public-sector
research institutions in industrialised countries
should be forged to bring biotechnology to bear
on the agricultural problems of developing
countries. Developing countries can address
funding and personnel constraints by providing
incentives to the private sector to engage in such
research, by collaborating with international
research programmes, and by seeking privateand public-sector partners in industrialised
countries. They should be encouraged to adopt
regulations that provide an effective measure of
biosafety without crippling the transfer of new
products to small farmers.
The fourth priority area of action is to promote
sustainable agricultural intensification and assure
sound management of natural resources. Publicand private-sector investments in infrastructure,
conservation, soil improvements, primary
education and health care, and agricultural
research must be expanded in areas with
significant agricultural potential, fragile soils, and
large concentrations of poverty to effectively
address their problems of poverty, food
insecurity, and natural resource degradation
before they worsen or spill over into other
regions. In areas of current low productivity but
significant agricultural potential, public policy and
public-sector investment should promote
sustainable use of existing natural resources to
enhance the productivity of agriculture and other
rural enterprises. Incentives should be provided
to farmers and local communities to invest in and
protect natural resources and to restore
degraded lands. Clearly specified systems of
rights to use and manage natural resources,
including land, water, and forests, should be
established and enforced. Local control over
natural resources must be strengthened, and
local capacity for organisation and management
improved. Farmers and communities should be
encouraged to implement integrated soil fertility
programmes in areas with low soil fertility
through policies to assure long-term property
rights to land, access to credit, improved crop
varieties, and information about production
systems; through effective and efficient markets
for plant nutrients, and investments in
infrastructure and transportation systems; and
through temporary fertiliser subsidies where
prices are high due to inadequate infrastructure
or poorly functioning markets. Integrated pest
management programmes should be promoted
as the central pest management strategy to
reduce use of chemical pesticides, remove
pesticide subsidies, and increase farmer
participation in developing effective and
appropriate strategies of pest management.
Water policies should be reformed to make better
use of existing water supplies by providing
appropriate incentives to water users, improving
procedures for water allocation, and developing
and disseminating improved technology for water
supply and delivery.
Policies and institutions that favour
large-scale, capital-intensive
enterprises over small-scale, labourintensive ones should be removed.
The fifth priority area of action is to develop
effective, efficient, and low-cost agricultural input
and output markets. Governments should phase
out inefficient state-run firms in agricultural input
and output markets and create an environment
conducive to effective competition among private
agents in order to provide efficient and effective
services to producers and consumers.
Governments should identify their role in
agricultural input and output markets and
strengthen their capacity to perform this role
better while disengaging themselves from
functions that should be undertaken by the
private sector. Policies and institutions that
favour large-scale, capital-intensive enterprises
over small-scale, labour-intensive ones should
be removed. Market infrastructure of a publicgoods nature, such as roads, electricity, and
communications facilities, should be developed
and maintained by direct public-sector
investment or effective regulation of privatesector investment. Governments should develop
and enforce standards, weights and measures,
and regulatory instruments essential for effective
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
functioning of markets. Development of smallscale credit and savings institutions should be
facilitated. Technical assistance and training
could be provided to create or strengthen smallscale, labour-intensive competitive rural
enterprises in trade, processing, and related
marketing activities.
The sixth priority area of action is to expand and
realign international assistance. The current
downward trend in international development
assistance must be reversed, and industrialised
countries allocating less than the United Nations
target of 0.7% of their gross national product
(GDP) should rapidly move to that target. Official
development assistance, which is only a small
fraction of the resources required by developing
countries, must be allocated to effectively
complement national and local efforts. Official
government-to-government assistance should be
made available primarily to countries that have
demonstrated commitment to reducing poverty,
hunger, and malnutrition and to protecting the
International development
assistance must be realigned to low-income
developing countries, primarily in Sub-Saharan
Africa and South Asia where the potential for
further deterioration of food security and
degradation of natural resources is considerable.
In higher-income developing countries,
concessional aid such as grants should be
replaced by internationally available commercial
capital, freeing resources for the low-income
countries. To improve effectiveness of aid, each
recipient country should develop a coherent
strategy for achieving its goals related to food
security, poverty, and natural resources, and
should identify the most appropriate uses of
international assistance.
The Role Of Women In Achieving The 2020
Women are key economic actors throughout the
world. They play essential roles in agriculture,
industry, manufacturing, and services, as well as
in the home. Women account for 70–80% of
This section benefits greatly from results of research by
IFPRI colleagues, particularly Lawrence Haddad and Agnes
household food production in Sub-Saharan
Africa, 65% in Asia, and 45% in Latin America
and the Caribbean. They achieve this despite
unequal access to land, to inputs such as
improved seeds and fertilisers, and to
information. Much of women's work is invisible in
official statistics, because it is still to a
considerable extent concentrated in subsistence
production, in the informal sector, and in
household production. Partly because it is
invisible and partly because high-level decisionmakers in development activities are mostly men,
women's contributions are frequently overlooked
and the human resources provided by women
are poorly utilised. Overlooking the potential
economic and social benefits from more effective
integration of women into mainstream
development is costly to developing countries
and results in less development gains per dollar
spent in development projects in addition to the
impact on the wellbeing of the women
One of the critical lessons from 20 years of
research on this topic is that the actual and
potential role of women in development is so
large that it cannot effectively be dealt with in
isolation. Women must be fully integrated as
decision-makers, resources for development,
and beneficiaries. Many women are selfemployed as informal sector traders and microentrepreneurs. As micro-entrepreneurs, they
face innumerable constraints, many of which are
not faced by men. They frequently lack access to
credit and savings institutions, and they
frequently produce goods and services for local,
small markets suffering from demand constraints.
Such demand constraints in rural areas are most
effectively alleviated through investment in
agriculture, which in turn generates incomes
among farmers. Small farmers earning more
income tend to spend a large share of the
additional income on products and services
produced locally by the informal sector. This
linkage effect between incomes of small farmers
and incomes of other rural poor, including
women, is very strong in many developingcountry settings, particularly when the
agricultural sector produces both for the export
market and for the domestic market.
Chapter 7: Achieving the 2020 Vision, with Special Reference to Gender Issues
IFPRI research in a number of Asian and African
countries shows that, for each dollar generated
among small farmers, about US$ 1.50 of
additional incomes are generated outside
agriculture, primarily among the rural poor.
Women from low-income households in
developing countries spend much more time
working than men. However, the productivity of
their work is frequently low. The human resource
embodied in women is poorly utilised in the
development process. Policies and projects that
would upgrade the quality of women's labour,
enhance their productivity, and strengthen their
participation in decision-making processes will
generate more development per dollar spent.
Such policies and projects include education of
girls and women, skill development for women,
generation and distribution of appropriate
technology needed to increase the productivity of
work done by women both in and outside homes,
and empowerment of women in decision-making
processes regarding production, reproduction,
and distribution. In addition to the greater impact
on development in general and on women's own
wellbeing, these policies and programmes are
also likely to further enhance efforts to alleviate
human misery such as food insecurity and
malnutrition, partly because of women's strong
roles in care giving and partly because of their
strong roles in agriculture and other parts of the
food system.
Differences in the productivity between men and
women disappear when women are given access
to the same productive resources, technology,
and information. Failure to make available
resources, technology, knowledge, and access to
decision-making entails a high cost to developing
countries in terms of foregone economic growth
and foregone improvements in the wellbeing of
the disadvantaged groups of developing-country
populations including women themselves.
Although women are responsible for a very large
share of food and agricultural production and
processing, they seldom receive extension
services, technical assistance, credit, or input
subsidies. They frequently do not have access
to financial or capital markets, and they are in
most cases barred from obtaining legal rights to
land. Laws governing women's rights to land
vary widely. Some religious laws prohibit female
landownership. Even when civil law gives
women the right to inherit land, local custom may
rule otherwise. The weakness of women's land
rights results in an inability to use land as
collateral to obtain access to credit. Social and
cultural barriers, women's lower educational level
relative to men, and their lack of familiarity with
loan procedures may also limit their ability to
obtain credit from formal as well as informal
sources. Providing women with basic education
would help raise agricultural productivity and
incomes, for better educated farmers are more
likely to adopt new technology.
The weakness of women's land rights
results in an inability to use land
as collateral to obtain access to credit.
Education and skill developments aimed at
agricultural production are usually focused on
men, and research to generate appropriate
technology is usually not guided by the needs of
women, even though they are responsible for a
very large share of the production for which the
technologies are being developed. Legislation is
needed to guarantee women's rights to inherit
and own land. Women should be fully integrated
into efforts to expand the productivity in food
production combined with sustainable use of
natural resources.
Efforts should be made to reduce the
conflicts that women face
in time allocation.
At a time when international trade liberalisation
and policy reforms in many developing countries
promote export orientation, it is critical that
complimented by measures that facilitate
women's access to resources. They should also
be given access to savings and loan institutions,
and to technical assistance and training. Exportoriented agriculture may expand jobs for women
in agribusiness in rural areas. Efforts should be
made to reduce the conflicts that women face in
time allocation. Efforts should also be made to
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
generate productivity-increasing technology for
women in various aspects of agricultural
processing and marketing.
Policies, projects, and technology focused on
further integration of women into mainstream
development must focus on increasing the
productivity per unit of time spent by women in
both household and other economic activities.
Women in low-income households are faced with
very severe time constraints and efforts to
integrate women into mainstream development
by asking them to spend more time are likely to
either fail or entail heavy costs in terms of
foregone benefits from current activities such as
child care.
With respect to the economic access to available
food, a large number of recent studies have
shown that improvements in household welfare
depend not only on the level of household
income but also on who earns and controls that
income. These studies find that women, relative
to men, tend to spend their income
disproportionately on food for the family.
Furthermore, women's incomes are more
strongly associated with improvements in
children's health and nutritional status than are
men's incomes. Therefore, greater gender
equality in income earning and in decisionmaking regarding the spending of incomes in
low-income households are likely to be more
effective in alleviating food insecurity and
malnutrition than the existing gender inequality in
income earning and decision-making.
Ensuring the nutrition security of the household,
through the combination of food, health care, and
child care is almost exclusively the domain of
women. They spend a great deal of time in
these activities, and they are constantly faced
with difficult choices in their time allocation.
Increased time spent in generating incomes and
in using health and education facilities can
improve child nutrition, but the loss of direct time
spent in child care is likely to have a negative
effect. Increasing female employment outside
the home may increase women's bargaining
power with respect to the use of household
incomes and resources. Technology is urgently
needed to increase the productivity of women per
unit of time spent in agriculture, household
maintenance, income earning enterprises, and
child care in order to assist women in reducing
the overall time requirements for these activities
without negative effects on themselves and the
household. More details on the role of women in
food security is presented by Quisumbing et al.,
Food insecurity has long been perceived by
some to be primarily a problem of insufficient
food production rather than insufficient access to
food. Yet, as enough food is being produced to
meet the basic needs of every person in the
world, it is evident that the persistence of food
insecurity— about 840 million chronically undernourished people and 185 million malnourished
children— is increasingly attributable to difficulties
in accessing sufficient food, primary health care,
education, and good sanitation. Food-insecure
people simply do not have the means to grow
and/or purchase the needed food and gain
access to the services needed. Empowering
every individual to have access to remunerative
employment, to productive assets such as land
and capital, and to productivity-enhancing
resources such as appropriate technology, credit,
education, and health care is essential. Besides
enabling every person to acquire the means to
grow and/or purchase sufficient food to lead
healthy and productive lives, assuring a foodsecure world calls for producing enough food to
meet increasing and changing food needs and
for meeting food needs from better management
of natural resources.
With foresight and decisive action, we can create
the conditions that permit food security for all
people in coming years. Much of the action
required is not new or unknown. For instance, we
know that increased productivity in agricultural
production helps not only to produce more food
at lower unit costs and make more efficient use
of resources but also to raise the incomes of
farmers and others linked to agriculture and thus
improve their capacity to purchase needed food.
The action programme outlined earlier will
require all relevant parties— individuals,
households, farmers, local communities, the
private sector, civil society, national
governments, and the international community—
Chapter 7: Achieving the 2020 Vision, with Special Reference to Gender Issues
to work together in new or strengthened
partnerships; it will require a change in
behaviour, priorities, and policies; and it will
require strengthened cooperation between
developing and industrialised countries and
among developing countries. The world's natural
resources are capable of supporting sustainable
food security for all people, if current rates of
degradation are reduced and replaced by
sustainable use of natural resources (PinstrupAndersen and Pandya-Lorch, 1996).
World Food Security and World Food Summit
Plan of Action. FAO, Rome.
Policies and projects must empower
women in production, distribution,
and in reproductive decisions.
Pinstrup-Andersen P and Pandya-Lorch R (1996)
Food for all in 2020: can the world be fed without
damaging the environment? Environmental
Conservation 23(3): 226-234.
Women are key to food security. As an integral
part of development efforts, women must be
given equal access to productive resources and
to education, health care, and other factors that
increase their wellbeing and their human capital.
Education and skill development for girls, and
access to land, credit, and appropriate
technology for women must be accelerated.
Policies and projects must empower women in
production, distribution, and in reproductive
decisions. Strategies must be developed to
increase women's productivity per unit of time
both in paid work and in domestic production so
that women can increase their incomes without
sacrificing additional time, their children's
welfare, or their own health and nutritional status.
Quisumbing AR, Brown LR, Feldstein HS,
Haddad L, PeГ±a C (1995) Women: The Key to
Food Security. Food Policy Report. IFPRI,
Washington, DC.
A fuller understanding of the gender-specific
relationships in development and incorporation of
such understanding in the design and
implementation of policies and programmes will
help achieve the 2020 Vision for the benefit of all,
independent of gender.
Delgado C, Hopkins J, Kelly V
Agricultural Growth Linkages in Sub-Saharan
Africa. IFPRI, Washington, DC.
FAO (Food and Agricultural Organization of the
United Nations) (1996) Rome Declaration on
Hazell PBR and Röell A (1983) Rural Growth
Linkages: Household Expenditure Patterns in
Malaysia and Nigeria. Research Report 41.
IFPRI, Washington, DC.
IFPRI (International Food Policy Research
Institute) (1995) A 2020 Vision for Food,
Agriculture, and the Environment: The Vision,
Challenge, and Recommended Action. IFPRI,
Washington, DC.
World Bank (1993) The East Asian Miracle:
Economic Growth and the Public Policy. Oxford
University Press, New York.
Tim Frankenberger (CARE): The emphasis of the
2020 vision has focused on agriculture, but one
thing we cannot lose sight of is urbanisation. By
the year 2020 the majority of African people will
be living in cities. How can this issue be
integrated more into the 2020 vision?
Per Pinstrup-Andersen: I agree with you. We do
have to pay much more attention to the urban
areas because there is an excessive rural-tourban migration. The urban areas have serious
problems absorbing the inflow of people, so we
are seeing a tremendous increase in urban food
insecurity and urban poverty. We are doing
much more at IFPRI in the area of urban food
security. However, what worries me is that if we
stress the urban problems, we are giving licence
to urban decision-makers to continue the urban
bias that has existed for so many years. I think
the emphasis is still too heavy on urban
problems. There are all kinds of political reasons
for that. So I wish to continue to stress the rural
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
areas with due emphasis being given to the
urban areas. One of the main reasons we have
excessive out-migration— excessive in the sense
that the urban areas cannot absorb the people as
fast as they come in— is that living conditions are
so poor in the rural areas. I don’t think we have
a disagreement, it’s a matter of what you
emphasise. There is still a tremendous urban
bias in most poor countries.
Christian Drevon (Institute for Nutrition Research,
Oslo): I would like to point out a topic that hasn’t
been discussed very much, that is, the very
heavily-subsidised farming production of dairy
products and meat. In Norway, for example,
close to US$ 1 billion is spent per year in support
of the dairy industry. Dairy products create a lot
of coronary heart disease. This is also projected
to happen in developing countries. Would you
care to comment on that?
Per Pinstrup-Andersen: I’m not sure that I see
the link between agricultural subsidies and
chronic diseases because most of the
agricultural subsidies result in higher prices for
animal products than what you would otherwise
have in the areas where the subsidies exist. But
I think that the agricultural subsidies in the
European Union, Japan, the United States and a
few other places have done damage to
developing countries. I don’t think that there’s
any question about that. It’s not only that they
keep the international prices slightly lower than
they would otherwise be, it’s also a problem of
getting rid of the surplus production that results
from these subsidies. There has been a
considerable amount of damage done, for
example, in Africa, from dumping surplus food
from the United States and from Western
Europe. But I don’t quite see the link with
chronic diseases. We do talk about agricultural
subsidies in developed countries and it does
have some negative effects on developing
countries. Hopefully, they will be replaced
gradually as part of the WTO round, as trade
liberalisation occurs.
Hopefully, we will
eventually get rid of agricultural subsidies
because they are not helping poor people in
developing countries.
Anna Ferro-Luzzi (Italy): I would like to raise the
issue of biotechnology— in particular of the GMO,
the genetically modified organisms. In your talk
you addressed this issue from the point of view
of improving agricultural yield and productivity. I
do not question how much of that improvement is
truly in the reach of the poor African farmer,
rather, my concern relates to the issues. As
member of the Scientific Committee on Food of
the European Commission, I am often asked to
express an opinion on the safety of food products
that have undergone genetical modification.
Such a judgement obviously includes their
nutritional adequacy. Currently, however, our
judgement of safety and nutritional adequacy is
based on what is called substantive equivalence.
In brief, this equivalence requires that the
composition of the genetically modified product
does not differ from that of the unmodified
product. From the nutritional point of view, this is
habitually referred to in terms of macronutrients.
The micronutrient composition, such as vitamins
and trace elements, is usually not taken in
consideration. And even less attention is paid to
the presence, type and amount of several nonnutrients— such as the polyphenols— which are
now being recognised as playing an important
role in relation to human health. Don’t you think
that before we change the compositional profile
of the food we consume, we should be
concerned with trying to know more of what this
food contains before it was modified? And should
we not be obliged to enlarge the concept of
substantial equivalence to include micronutrients
and other bioactive compounds?
Per Pinstrup-Andersen: The concern that I have
is that the risk levels that individual households
are willing to accept differ a great deal among
households. Let me explain what I mean. If the
agricultural research community could develop a
drought-tolerant maize variety that would triple or
quadruple yields in West Africa and reduce the
losses during drought periods by means of
genetic engineering, let us not outlaw that
possibility before we see whether it is possible.
Right now, nobody is working on that. The
private sector, which is responsible for most of
the biological engineering for agriculture, is not
working on that. Partly because there is very
little profit to be had in the short-term in West
Africa from this kind of thing, and partly because
they are being told by governments where they
operate that they can’t even field test it.
Chapter 7: Achieving the 2020 Vision, with Special Reference to Gender Issues
Therefore, what I’m suggesting is, that while we
in Europe may choose to outlaw genetically
modified maize, even though all scientific
evidence and all common sense tells us that it is
no more dangerous than the maize produced
using traditional plant breeding methods,
shouldn’t we give the West African farmer who is
trying to feed her children from one or two acres
of maize the choice to say �I’m willing to take the
chance on this genetically modified maize
because the alternative is a lot worse’? I don’t
want to be dramatic about it, but we should be
careful not to impose those kinds of values that
we may be able to afford in Europe on other
parts of the world. I could give many other
examples of this. If the research community
decides that it is going to use modern science to
solve poor people’s problems, we will see
tremendous progress during the next 10 to 15
years. But right now, there is virtually nothing
invested in solving these problems— that’s what
worries me.
Richard Jolly: I want to thank you for mentioning
the World Trade Organization. I would like to ask
a question and to make a point. The question is,
in your experience, what are the ways to get
across politically the importance of nutrition, and
particularly actions that would help undernutrition
in developing countries, in discussing issues of
the sort that go before the WTO? The point I
want to make is that one of the greatest
economists of the 20 th century, John Maynard
Keynes, in sketching out over 50 years ago how
an international trade organisation should work,
took the issue of how to stabilise agricultural
When discussing at what level
agricultural policies should be stabilised, he said
(1) at a level that is efficient, and (2) at a level
sufficient to guarantee peasant producers
adequate income and nutrition. This brought into
the very heart of economic policy making,
concern for nutrition. I think we should all be
aware of that.
Per Pinstrup-Andersen: There are a number of
points that I would like to make. If poor countries
are to improve their food security through trade
liberalisation, there are many domestic policies
that would have to be dealt with in those
countries. You cannot solve your domestic policy
problems by liberalising international trade. We
have done considerable research to prove that
point. In particular, for a period of time, West
African countries thought that they could live with
very bad domestic policies if they could integrate
regionally. It doesn’t work that way. There are
so many internal constraints in poor countries
that make it very difficult to benefit from
international trade liberalisation. But one of the
things that we need to tell policy makers from
poor countries, is that when you do participate in
WTO negotiations, insist on industrialised nations
opening up their markets for the products that
you can export. Take the new initiative by the
United States for expanded trade with Africa.
Look at what commodities the Americans are
willing to accept from Africa on concessional
terms, and granted, textiles are in there— they
are very important for some African countries.
But guess what’s not in there? Peanuts,
groundnuts, tobacco, sugar, among others. Latin
America over the last 10 years has opened up its
markets much more than Europe and North
America have opened up theirs, and let’s not
forget Japan. There has to be more equality in
opening up markets. Good nutrition is an
investment in future economic growth that can
benefit everybody— it is not just a hand-out to
poor people. Using that as an argument to get
into international trade would be helpful as well.
George Kent (University of Hawaii): You spoke
about the 2020 vision for food and agriculture,
with a world where every person has access to
sufficient food, and then you proceed to say that
if that is indeed the vision and the motivation,
then we need to take the following steps. The
problem is that is not the driving vision. In most
places in the world, agriculture and food
production systems are not there for the purpose
of alleviating malnutrition. They are there for an
entirely different purpose, leading to the question
�how are you going to bridge that gap’. We have
repeatedly said here that if the political priorities
and will were there, we could get these
programmes up to scale and solve the problems,
but that is not, in fact, the driving vision. You
then also mentioned briefly the question of the
right of every person to have adequate food and
nutrition, but then we didn’t speak about the
corresponding obligations. I think we need more
clarity here about the exact role of governments
and their obligations in this system.
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Per Pinstrup-Andersen: Yes, but I think that a
number of the governments that we are
interacting with, do respond to better information.
Even if they don’t wish to respond to better
information, it is much more difficult to ignore it.
The best opportunity for a bad government to
continue to be bad, is ignorance. What I am
arguing is, let’s get the information on the table
for everyone to see; that 50% of the world’s poor
people and x% of the poor people in a particular
country are in rural areas. You, governments,
are ignoring the rural areas, and here are the
George Kent (University of Hawaii): If good
governments are defined primarily in terms of
maximising economic growth, then the fact that
the poor people are not visible is an important
Per Pinstrup-Andersen: What we have been
talking about all day is that better nutrition is an
investment in broad-based economic growth. I
don’t think that there’s a conflict there— it may be
that governments do not accept that.
Fernando Viteri (UNU): There has been a push in
many developing countries in promoting cash
crop productions by communities and by
cooperatives in those communities. I am aware
of a study in a cooperative in Guatemala, which
was promoting cash crop products. It turned out
to be unsustainable and it also did not improve
the nutrition of that community. Can you explain
to us why, whether this is a generalised trend,
and what to do to avoid it?
Per Pinstrup-Andersen: The project you
mentioned in Guatemala, I suspect, was the
project that IFPRI participated in. IFPRI has
done research on cash cropping projects around
the world, and what we find is that most of the
cash cropping projects end up improving the
economic wellbeing of the small farmers
participating. Not all of them improve nutrition
and where they don’t, it’s because the economic
wellbeing was not the constraint for better
nutrition— it was access to primary health care, to
sanitation, to clean water, or to other things.
Again, we cannot sit here and design magic
bullets for solving the problems because the
solutions will vary from one location to another.
What was consistent across all, or almost all of
the studies we did, was that the small farmers
gained economically, but nutrition did not
improve in all cases. But nutrition did not
deteriorate. There’s an old story that goes back
20 years that cash cropping is bad for nutrition.
We could not find any evidence of that anywhere.
Fritz Kaferstein (WHO): A very short comment to
echo the concern of Per with regard to
biotechnology and its importance for developing
countries. The WHO has gone through a
consultative process with FAO, to provide
guidance with regard to the assessment of the
safety of foods produced by biotechnology. It
has also looked at the importance of
biotechnology— the recombinant DNA technology
(rDNA)— for developing countries. In 1996, we
had a consultation on biotechnology and food
safety, and in the consultation report there is a
paragraph devoted to the application of rDNA
technology in developing countries. It is five
lines, if I am permitted to quote from this report.
�Recombinant DNA technology has broad
applications in developing countries and has a
potential for very positive impact on their
economies, which are frequently agriculturallybased. In this context, a view was expressed
that rDNA technology might be of greater
importance for developing countries than for
industrialised countries. In particular, developing
countries look to rDNA technology as a means
for addressing the need to produce sufficient
quantities of nutritionally adequate and safe food
for their growing populations. The benefits of this
technology are likely to impact directly on people
at the production level as this technology is
extremely easy to transfer’.
Bill Clay (FAO): I would like to make a quick
point. I would like to make the case for the need
to continue to invest in high potential areas.
There can be tremendous improvements and
very quick returns from that, both in terms of
expanding and diversifying food production,
ensuring adequate food for cities and developing
market structures, and for creating the
employment and wealth that will continue to
support the investment needed in health, water,
and education. I wouldn’t quite make the case
that we always need to be under the spotlight—
we need to make more light.
Chapter 7: Achieving the 2020 Vision, with Special Reference to Gender Issues
Per Pinstrup-Andersen: I didn’t mean to say that
we should stop investing in high potential areas,
and I’m glad you pointed that out to give me an
opportunity to comment. I’m talking about the
balance. The balance is skewed too far towards
the high potential areas. We need to invest
much more in the low potential areas than what
we have done in the past.
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Chapter 8: Gender and Nutrition in the Global Burden of Disease, 1990 to 2020
Chapter 8
Gender and Nutrition in the Global Burden
of Disease, 1990 to 2020
Christopher Murray and Alan Lopez1
In general, statistics on the health status of
populations suffer from several limitations that
reduce their practical value to policy makers.
First, they are partial and fragmented. In
many countries even the most basic data—
the number of deaths from particular causes
each year— are not available. Even where
mortality data are available, they fail to
capture the impact of non-fatal outcomes of
disease and injury, such as dementia or
blindness, on population health.
Second, estimates of the numbers killed or
affected by particular conditions or diseases
may be exaggerated beyond their
demographically plausible limits by wellintentioned epidemiologists who also find
themselves acting as advocates for the
affected populations in competition for
scarce resources. If the currently available
epidemiological estimates for all conditions
were right, some people in a given age
group or region would have to die several
times over to account for all the deaths that
are claimed!
Third, traditional health statistics do not
allow policy makers to compare the relative
cost-effectiveness of different interventions,
such as, for example, the treatment of
ischaemic heart disease versus long-term
care for schizophrenia. At a time when
people’s expectations of health services are
growing and funds are tightly constrained,
such information is essential to aid the
rational allocation of resources.
To address these, and other limitations of
traditional health statistics, the World Bank, in
collaboration with WHO, commissioned a new
study of the Global Burden of Disease (GBD) in
1991 to provide a new holistic assessment of
global (and regional) health conditions in 1990.
Most developing countries still have only limited
information about how their populations die. One
of the chief objectives of the GBD has been to
develop comprehensive, internally-consistent
estimates of how many people died of each
major cause in 1990 worldwide. No such data
set was available before the GBD began work.
The methods are briefly described in the Annex.
A selection of key results follows.
Estimating Mortality
Deaths were classified using a tree structure.
The first level of disaggregation comprises three
broad cause groups:
Group I: Communicable, maternal,
perinatal, and nutritional conditions.
Group II: Non-communicable diseases.
Group III: Injuries.
Each group was then subdivided into subcategories: for example, cardiovascular diseases
and malignant neoplasms (cancers) are two subcategories of Group II. Beyond this level, there
are two further disaggregation levels so that 107
individual causes for which codes have been
included in the Ninth Revision of the International
Classification of Diseases (ICD-9), such as
This paper is based on the Summary of the Global Burden of Disease Study prepared by Phylidda Brown which in turn is based
on the book edited by the authors entitled �The Global Burden of Disease’and published by Harvard University Press in 1996.
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
tuberculosis, stomach cancer, or road traffic
accidents, can be listed separately.
A demographic data set giving information on
population size and the distribution of deaths for
each region was developed especially for the
GBD. Next, to reach estimates of the number of
deaths by cause, we drew on four broad sources
of data:
Vital registration systems.
These are
complete only for the Established Market
Economies and the Formerly Socialist
Economies of Europe, although some vital
registration information is available for all
regions except China, India, and SubSaharan Africa (excepting South Africa).
Sample death registration systems. In
China, a set of 145 Disease Surveillance
Points, representative of both rural and
urban areas, and covering about 10 million
people, provides information on deaths by
cause. In India, Maharashtra State provides
full medical certification for at least 80% of
urban deaths, while a rural surveillance
system including more than 1300 primary
health care centres nationwide was used to
assess rural death patterns.
Epidemiological assessments. Epidemiologists have made estimates of deaths for
specific causes, such as malaria, in certain
These estimates combine
information from surveys on the incidence or
prevalence of the disease with data on casefatality rates for both treated and untreated
Cause-of-death models. Models are used to
check the validity of existing data by putting
demographic limits on epidemiological
estimates. Such models estimate the
distribution of deaths by cause in a
population from historical studies of the
relationship between the overall level of
mortality in a population and deaths from
broad groups of causes, such as
cardiovascular diseases. The model
developed for this study drew on a data set
of 103 observations from 67 countries
between 1950 and 1991.
Mortality Estimates for 1990
Worldwide, one death in every three is from a
Group I cause (communicable, maternal, and
perinatal conditions, and nutritional deficiencies).
Virtually all of these deaths are in the developing
regions. One death in ten is from Group III
causes (injuries) and just over half of all deaths
are from Group II causes (non-communicable
diseases). Figure 13 shows the proportionate
burden from each cause for developing and
developed regions.
Figure 13: Deaths by broad cause group, 1990
Developing regions
Developed regions
Group I
Group II
Group III
Group I
Group II
Group III
Note: Cause-of-death models. Models are used to check the validity of existing data by putting demographic limits on
epidemiological estimates. Such models estimate the distribution of deaths by cause in a population from historical studies of the
relationship between deaths from 12 broad groups of causes, such as cardiovascular diseases and infectious diseases, and the
total number of deaths. The models developed for this study drew on a dataset of 103 observations from 67 countries between
1950 and 1991.
Chapter 8: Gender and Nutrition in the Global Burden of Disease, 1990 to 2020
More surprising, perhaps, is the finding that, for
several major developing regions, more people
already die of Group II causes than Group I
causes. In Latin America and the Caribbean,
there are almost twice as many deaths from noncommunicable diseases as from Group I causes.
In China, there are four-and-a-half times as many
deaths from non-communicable diseases as from
Group I causes. The balance has also tipped
towards Group II causes in the Middle Eastern
Crescent and the region comprising Asia beyond
India and China, and the Pacific Islands. Only in
India and Sub-Saharan Africa do Group I causes
still dominate, accounting for 51% and 65% of
deaths respectively.
When the estimates are expressed in terms of
the probability of dying at a given age in a given
region, a striking picture emerges. For adults
under the age of 70, the probability of dying from
a non-communicable disease is greater in both
Sub-Saharan Africa and India than in the
Established Market Economies. The results
show that premature mortality rates from noncommunicable diseases are higher in
populations with high mortality and low income
than in the industrialised countries, which is
perhaps somewhat surprising and requires
further research.
The health of men in the Formerly Socialist
Economies of Europe is surprisingly poor. Based
on 1990 death rates, men face a 28% risk of
death between the ages of 15 and 60, the
highest risk in any region except Sub-Saharan
Africa. This excess is explained by a higher rate
of non-communicable diseases and also by a
higher risk of death from injury than for men in
the Established Market Economies.
Just over 50 million people died worldwide in
1990, with ischaemic heart disease (IHD)
causing more deaths than any other disease or
injury. Only 2.7 million of the 6.3 million people
who died of IHD lived in the developed world.
Cerebrovascular disease (stroke) killed 4.4
million people, of whom only 1.4 million were in
the developed world. Lower respiratory infections
(pneumonia) killed 4.3 million people, all but 0.4
million of them in the developing world.
Diarrhoeal diseases caused 2.9 million deaths,
virtually all in the developing world. The ten
leading causes together accounted for just over
half of all deaths (Table 7).
Table 7: The ten leading causes of death, 1990
Developed Regions
All Causes
1. Ischaemic heart disease
2. Cerebrovascular disease
3. Trachea, bronchus and
lung cancer
4. Lower respiratory
5. Chronic obstructive
pulmonary disease
6. Colon and rectum
7. Stomach cancer
8. Road traffic accidents
9. Self-inflicted injuries
10. Diabetes mellitus
Developing Regions
All Causes
1. Lower respiratory infections
2. Ischaemic heart disease
3. Cerebrovascular disease
4. Diarrhoeal diseases
5. Conditions arising during
the perinatal period
6. Tuberculosis
7. Chronic obstructive
pulmonary diseases
8. Measles
9. Malaria
10. Road traffic accidents
Cumulative %
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Worldwide in 1990, about 5 million people died of
injuries of all types, two-thirds of them men.
Most of these deaths are heavily concentrated
among young adults. In this age group, road
traffic accidents, suicide, war, fire, and violence
are all among the ten leading causes of death.
Among adults aged 15-44 years worldwide, road
traffic accidents were the leading cause of death
worldwide for men and the fifth most important
for women. For women between the ages of 15
and 44 years, suicide was second only to
tuberculosis as a cause of death. In China
alone, more than 180,000 women killed
themselves in 1990. In India, women face an
appallingly high risk of dying in fires: in 1990
alone, more than 87,000 Indian women died this
way. In Sub-Saharan Africa, by contrast, the
most important cause of injury deaths for both
women and men is war.
The Burden of Disability
The GBD Study suggests that disability plays a
central role in determining the overall health
status of a population. Yet that role has until now
been almost invisible to public health. The
leading causes of disability are shown to be
substantially different from the leading causes of
death, thus casting serious doubt on the practice
of judging a population's health from its mortality
statistics alone.
Most significantly, the study shows that the
burden of psychiatric conditions has been heavily
underestimated. Of the ten leading causes of
disability worldwide in 1990, measured as years
lived with a disability (YLDs), five were
psychiatric conditions: unipolar depression,
alcohol use, bipolar affective disorder (manic
depression), schizophrenia, and obsessivecompulsive disorder. Unipolar depression alone
was responsible for more than one in every ten
years of life lived with a disability worldwide.
Altogether, psychiatric and neurological
conditions accounted for 28% of all YLDs,
compared with 1.4% of all deaths and 1.1% of
years of life lost. The predominance of these
conditions is by no means restricted to the rich
countries, although their burden is highest in the
Established Market Economies. They were the
most important contributor to YLDs in all regions
except Sub-Saharan Africa, where they
accounted for a relatively modest 16% of the
The leading causes of disability are
shown to be substantially different
from the leading causes of death,
thus casting serious doubt
on the practice of judging a
population's health from
its mortality statistics alone.
Alcohol use is the leading cause of male
disability— and the tenth largest in women— in
the developed regions. More surprisingly,
perhaps, it is also the fourth largest cause in men
in developing regions. The remaining important
causes of YLDs were anaemia, falls, road traffic
accidents, chronic obstructive pulmonary
disease, and osteoarthritis (Table 8).
Table 8: The leading causes of disability, world, 1990
All Causes
1. Unipolar major depression
2. Iron deficiency anaemia
3. Falls
4. Alcohol use
5. Chronic obstructive pulmonary disease
6. Bipolar disorder
7. Congenital anomalies
8. Osteoarthritis
9. Schizophrenia
10. Obsessive-compulsive disorders
Total (millions)
% of Total
Chapter 8: Gender and Nutrition in the Global Burden of Disease, 1990 to 2020
(49%) in developing regions. In Sub-Saharan
Africa, two out of three years of healthy life lost
were due to Group I conditions. Even in China,
where the epidemiological transition is far
advanced, a quarter of years of healthy life lost
were due to this Group. Worldwide, five out of
the ten leading causes of disease burden are
Group I conditions: lower respiratory infections
(pneumonia); diarrhoeal disease; perinatal
conditions; tuberculosis; and measles.
developing countries, malaria is added to this
already daunting list (Figure 14).
The peoples of Sub-Saharan Africa and India
together bore more than four-tenths of the total
global burden of disease in 1990, although they
made up only 26% of the world’s population in
that year. By contrast, the Established Market
Economies and the Formerly Socialist
Economies of Europe, with about a fifth of the
world’s population between them, together bore
less than 12% of the total disease burden. China
emerged as substantially the most �healthy’ of
the developing regions, with 15% of the global
disease burden and a fifth of the world’s
population. Put differently, about 579 years of
healthy life were lost for every 1000 people in
Sub-Saharan Africa, compared with just 124 for
every 1000 people in the Established Market
Economies, highlighting the massive inequalities
of world health at the end of the 20th century.
The burden of injury in 1990 was highest in the
Formerly Socialist Economies of Europe, where
almost 19% of all burden was attributed to this
group of causes. China had the second highest
injury burden, Latin America and the Caribbean
the third, and Sub-Saharan Africa the fourth.
Even in the Established Market Economies,
however, the burden of injuries— dominated by
road traffic accidents— was almost 12% of the
Communicable, maternal and perinatal
conditions, and nutritional deficiencies persist as
a problem for the whole world. Even though
these Group 1 conditions accounted for only 7%
of the burden in the Established Market
Economies and less than 9% in the Former
Socialist Economies, they nevertheless made up
more than four-tenths of the total global burden
of disease in 1990, and almost half of the burden
Figure 14: The burden of disease, by broad cause group, 1990
Percent of total DALYs
Group I
Group II
Group III
Note: EME: Established Market Economies; FSE: Formerly Socialist Economies; CHN; China; LAC: Latin America and the
Caribbean; OAI: Other Asia and Islands; MEC: Middle Eastern Crescent.
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
In almost all regions, unintentional injuries were a
much bigger source of ill-health in 1990 than
intentional injuries such as interpersonal violence
and war. The only exception was the Middle
Eastern Crescent, where unintentional and
intentional injuries took an approximately equal
toll because of a particularly high burden of war
in the region at the time.
status. While a few leading conditions— such as
lower respiratory infections, diarrhoeal diseases,
and perinatal conditions— are at the top of both
lists, there are 14 conditions in the top half of the
list for disease burden that are in the bottom half
of the list for deaths. Depression is the most
marked of these, falling within the top ten for
disease burden, but the bottom ten for deaths.
When causes of death are compared, in rank
order, with causes of disease burden, substantial
differences emerge, again reinforcing the need to
take non-fatal conditions into account as well as
deaths when assessing a population's health
The leading causes of disease burden worldwide
in 1990 were broadly similar to those for the
developing regions. (Table 9).
Table 9: Ten leading causes of disease burden (DALYs),
developing world, 1990
All Causes
1. Lower respiratory infections
2. Diarrhoeal diseases
3. Conditions arising during the perinatal period
4. Unipolar major depression
5. Tuberculosis
6. Measles
7. Malaria
8. Ischaemic heart diseases
9. Congenital anomalies
10. Cerebrovascular diseases
Although in infancy and early childhood, girls and
boys suffer from broadly similar health problems,
striking sex differences emerge in adults. First,
disproportionately from their reproductive role.
Although the burden of reproductive ill-health is
almost entirely confined to the developing
regions, it is so great that even worldwide,
maternal conditions make up three out of the ten
leading causes of disease burden in women
between the ages of 15 and 44 years. In
developing regions, five out the ten leading
causes of DALYs are related to reproductive illhealth, including the consequences of unsafe
abortion and chlamydia. Almost all of this loss of
healthy life is avoidable.
However, poor reproductive health is far from
being women's sole concerns. In both developing
and developed regions, depression is women's
leading cause of disease burden. In developing
Total (millions)
% of Total
regions, suicide is the fourth. Thus, while
programmes to reduce the unacceptably high
burden of poor reproductive health must remain
a high priority for years to come, women's
psychological health also deserves much more
For men aged 15-44 years, road traffic accidents
are the biggest cause of ill-health and premature
death worldwide, and the second biggest in
developing regions, surpassed only by
depression. Alcohol use, violence, tuberculosis,
war, bipolar affective disorder, suicide,
schizophrenia and iron-deficiency anaemia make
up the remainder of the list in developing
countries. The high toll of road traffic accidents
in developing regions has received relatively little
attention from public health specialists in the
Chapter 8: Gender and Nutrition in the Global Burden of Disease, 1990 to 2020
Risk Factors for Death and Disability
Exposure to particular hazards, such as tobacco,
alcohol, unsafe sex or poor sanitation, can
significantly increase individuals' risks of
developing disease. These hazards, or risk
factors, are significant contributors to the total
global disease burden and health policy makers
need accurate information on their impact if they
are to devise effective prevention strategies.
Until now, however, there have been few
attempts to measure the burdens of these risk
factors, or to express them in a currency that can
be compared directly with the burdens of
individual diseases.
How the Burden of Risk Factors
Was Assessed
The burden of disease or injury in a population
today that can be attributed to past exposure to a
given risk factor is, essentially, an estimate of the
burden that could have been averted in the
population if that particular risk factor had been
eliminated. More precisely, this is defined as the
difference between the currently observed
burden and the burden that would be observed if
past levels of exposure had been equal to a
specified, reference distribution of exposure. In
general, to calculate this, it is necessary to know:
(a) the relative risk at different levels of exposure
for each cause of death and disability linked to
the factor; (b) the distribution of different levels of
exposure in the population; and (c) the burden of
disease or injury due to each of the causes
linked to the factor. Depending on the nature of
the risk factor, the reference distribution against
which relative risk is compared could be zero
exposure for the whole population, a population
distribution of exposure from low to high levels
based on observed populations, or an arbitrary
distribution. For this study, we used, wherever
possible, zero exposure as the reference, except
for risk factors such as hypertension, where
clearly no one can be said to exposed to 'zero'
sanitation and hygiene, unsafe sex, alcohol,
tobacco, and occupation. Together, these six
hazards accounted for more than one-third of
total disease burden worldwide in 1990 (see
Table 10). Of the six, malnutrition and poor
sanitation were the dominant hazards,
responsible for almost a quarter of the global
burden between them. Unsafe sex and alcohol
each contributed approximately 3.5% of the total
disease burden, closely followed by tobacco and
occupational hazards with just under 3% each.
These are comparable to the burdens caused by
tuberculosis and measles.
Not surprisingly, there are major inequalities
between regions and between men and women
in the burdens of most risk factors. For example,
the ill-health consequences of unsafe sex—
which include both infections and the
complications of unwanted pregnancy— are
borne disproportionately by women in all regions.
In young adult women in Sub-Saharan Africa,
unsafe sex accounts for almost one-third of the
total disease burden.
… malnutrition and poor sanitation
were the dominant hazards,
responsible for almost a quarter
of the global burden between them.
… Not surprisingly, there are major
inequalities between regions and
between men and women in the
burdens of most risk factors.
Tobacco and alcohol currently cause their
heaviest burdens in men in the developed
regions. In these regions, the two together
accounted for more than one-fifth of the total
burden in 1990. However, the health burdens of
smoking and drinking are far from being the
exclusive preserve of the industrialised world.
The recent rapid increase in tobacco use in Asia
and other developing regions is expected to kill
many more people in the coming decades than
have so far died in the developed regions.
Results: The Contributions of Malnutrition to
the Global Burden of Disease
Of the ten risk factors studied, the most
significant were malnutrition, poor water,
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Table 10: Global burden of disease and injury attributable to selected risk factors, 1990
Risk Factor
Poor water
supply, sanitation
& personal &
domestic hygiene
Unsafe sex
Physical inactivity
Illicit drugs
Air pollution
As % of
As % of
As % of
As % of
Source: Murray and Lopez (1997)
The impact of alcohol varies between regions not
only because of different levels of use in each
population, but also because of differences in the
age structure of those populations. Alcohol has
consistently been shown to provide some
protection against death from ischaemic heart
disease, but to increase the risk of several other
diseases, such as alcoholic psychoses,
pancreatitis, some cancers and cirrhosis of the
liver, as well as many injuries. Because of its
protective effect against ischaemic heart disease,
in populations where this condition is common
and injuries and violence are rare, alcohol may
prevent about as many deaths as it causes. In
the Established Market Economies, for instance,
this is probably the case. Nevertheless, alcohol
causes a severe disease burden in these rich
countries, because it causes so many injuries
and premature deaths and thus results in large
numbers of years lived with a disability and years
of life lost.
In Sub-Saharan Africa, the picture is very
different. There, ischaemic heart disease is
relatively uncommon, so the protective effect of
alcohol is far outweighed by its harmful effects in
increasing the rates of death and disability from
injuries. The contribution of alcohol to injuries is
also extremely high in Latin America and the
Caribbean, where alcohol use accounts for
almost 10% of total disease and injury burden, a
figure surpassed only in the developed regions.
Ultimately, alcohol is estimated to have caused
about three-quarters of a million more deaths in
1990 than it averted, with more than four-fifths of
the excess deaths in the developing regions.
Mason and colleagues (personal communication)
have developed estimates of the burden of
disease attributable to the physiological state of
undernutrition. Using data from 55 studies on
the relative risk of mortality as a function of the zscore weight-for-age nutritional indicator, they
estimated the relative risk per z-score for each
region. The proportion of the population that was
more than two z-scores below the median in a
population distribution of weight-for-age was
used to estimate the attributable fraction of child
mortality in each region. Similar calculations
were undertaken for morbidity, which shows
lower relative risks and attributable fractions. No
attempt was made to calculate the burden
attributable to mild undernutrition, i.e., the
population between one and two z-scores below
the median.
There are no relevant studies on the relative risk
of mortality from undernutrition for adults and
thus the burden of disease attributable to
undernutrition for the population aged 5-44 years
is calculated by assuming that the relative risks
for children aged 0-4 years were applicable to
this adolescent and adult population as well.
Chapter 8: Gender and Nutrition in the Global Burden of Disease, 1990 to 2020
Unfortunately, no convincing evidence has been
collected to support this relationship. We have,
therefore, only included the attributable burden
estimated for children in Table 11.
Table 11: Burden of disease attributable to underweight among children, 1990
Other Asia
and islands
Latin America
& the
As % of
As % of
As % of
As % of
Source: Murray and Lopez (1996)
Even limiting the estimates of the burden of
disease due to malnutrition to the effects of
underweight in children, it is a major cause of
disease burden in regions such as Sub-Saharan
Africa where it accounts for one-third of all
DALYs lost from disease and injury. In India
malnutrition accounts for 22% of disease burden,
and elsewhere in Asia and the Pacific Islands
about 15%.
Based on this analysis child
malnutrition is negligible as a source of DALYs in
more developed regions. This picture may be
very different, however, if micronutrient
malnutrition were taken into account. This work is
yet to be done. Similarly, underweight in adults
and overnutrition in all age groups, once taken
into account, may have an important impact on
these results.
Projections of Disease Burden, 1990-2020
Rather than attempt to model the effects of the
many separate direct, or proximal, determinants
of disease from the limited data that are
available, it was decided to consider a limited
number of socioeconomic variables: (1) income
per capita; (2) the average number of years of
schooling in adults, termed 'human capital'; and
(3) time, a proxy measure for the secular
improvement in health this century that results in
part from accumulating knowledge and
technological development. These socioeconomic variables show clear historical
relationships with mortality rates: for example,
income growth is closely related to the
improvement in life expectancy that many
countries have achieved this century. Because
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
of their relationships with death rates, these
socioeconomic variables may be regarded as
indirect, or distal, determinants of health. In
addition, a fourth variable, tobacco use, was
included, because of its overwhelming impact on
health status, using information from more than
four decades of research on the time lag
between persistent tobacco use— measured in
terms of 'smoking intensity'— and its effects on
Death rates for all major causes based on
historical data for 47 countries since 1950-91
were related to these four variables to estimate
the parametric values for each age/sex group,
which was then used to generate the projections.
A separate model was used for HIV and
modifications for the interaction between HIV and
tuberculosis. Three projection scenarios were
developed using different projections of the
independent variables.
Deaths from communicable, maternal, and
perinatal conditions, and nutritional deficiencies
(Group I) are expected to fall from 17.3 million in
1990 to 10.3 million in 2020. As a percentage of
the total burden, Group I conditions are expected
to drop by more than half, from 34% to 15%.
This projected reduction overall, despite
increased burdens due to HIV and tuberculosis,
runs counter to the now widely-accepted belief
that infectious diseases are making a comeback
worldwide. It reflects, in part, the relative
contraction of the world's 'young' population: the
under 15 age group is expected to grow by only
22% between 1990 and 2020, whereas the
cohort of adults aged between 15 and 60 is
expected to grow by more than 55%. In addition,
the projection reflects the observed overall
decline in Group I conditions over the past four
decades, due to increased income, education,
and technological progress in the development of
antimicrobials and vaccines. Even under the
pessimistic scenario, in which both income
growth and technological progress are expected
to be minimal, deaths from these conditions are
still expected to fall slightly to 16.9 million.
Clearly, it should not be taken for granted that
the progress of the past four decades against
infectious diseases will be maintained. It is
possible, for example, that antibiotic
development and other control technologies will
not keep pace with the emergence of drugresistant strains of important microbes such a
Mycobacterium tuberculosis.
If such a
frightening scenario were to prove correct, and if
case-fatality rates were to rise because of such
drug-resistant strains, the gains of the present
century could be halted or even reversed.
Undoubtedly, the continuing high toll of Group I
causes today leaves no room for complacency.
Nonetheless, the evidence to date suggests that,
as long as, and only if, current efforts are
maintained, Group I causes are likely to continue
to decline.
By 2020, the burden of disease attributable to
tobacco is expected to outweigh that caused by
any single disease. From its 1990 level of 2.6%
of all disease burden worldwide, tobacco is
expected to increase its share to just under 9%
of the total burden in 2020, compared with just
under 6% for ischaemic heart disease, the
leading projected disease. This is a global health
emergency that many governments and
international health agencies have yet to
In 1990, the three leading causes of disease
burden were, in descending order, pneumonia,
diarrhoeal diseases, and perinatal conditions.
The three conditions projected to take their place
by 2020 are ischaemic heart disease,
depression, and road traffic accidents.
Pneumonia is expected to fall to sixth place,
diarrhoeal diseases to ninth, and perinatal
conditions to eleventh.
Notably, measles,
currently in eight place, is expected to drop to
twenty-fifth. However, not all infectious diseases
are expected to decline, despite the projected
overall decrease of Group I conditions.
Tuberculosis is expected to remain at its current
level of seventh place, a substantial source of
disease burden for the foreseeable future. Of
perhaps even greater concern is the finding that
Chapter 8: Gender and Nutrition in the Global Burden of Disease, 1990 to 2020
HIV, currently twenty-eighth in the ranking, could
be as high as tenth by 2020.
Because of the growth of the adult fraction of the
population, the burdens of several important
types of injury are also likely to increase. For
example, young men are the population group
most frequently involved in road traffic accidents,
so if the young-adult proportion of the population
increases sharply, road traffic accidents are likely
to increase too. Indeed, according to the
baseline projection, road traffic accidents could
rise to third place from ninth worldwide.
Violence, currently nineteenth, could rise as high
a twelfth place, and suicide could climb from
seventeenth to fourteenth place.
Non-communicable diseases
were already, in 1990, the leading
causes of death worldwide and the
leading cause of disease burden.
Not surprisingly, these changes are not expected
to be evenly dispersed worldwide. The total
number of lost years of healthy life in the
Established Market Economics is likely to fall
slightly, while it will increase slightly in the
Formerly Socialist Economies of Europe.
Strikingly, however, Sub-Saharan Africa's future
looks disturbingly poor despite the decline in the
burden of Group I conditions that currently
dominate its health needs. Overall, the region
faces an increase in the number of lost years of
healthy life between 1990 and 2020, due mainly
to a steep projected rise in the burden of injuries
from road accidents, war and violence.
Several surprising findings emerged from this
first ever attempt to quantify global health status.
Perhaps most surprising was the fact that noncommunicable diseases were already, in 1990,
the leading causes of death worldwide and the
leading cause of disease burden. By measuring
non-fatal outcomes in a comparable fashion to
premature death, the massive, but hitherto
unknown disease burden from neuropsychiatric
conditions, especially depression, emerges as a
major global public health concern. Similarly
injuries, whether intentionally or unintentionally
inflicted, are a significant cause of burden in all
regions, typically accounting for around 10% of
the entire disease and injury burden. Projections
to the year 2020 carried out as part of the GBD
Study suggest that the significance of noncommunicable diseases will increase even
further in all regions, but particularly in China,
Latin America and the Caribbean, and parts of
Asia. Even in Sub-Saharan Africa, chronic
diseases by 2020 are projected to cause as
many deaths as all infectious diseases
combined. Other leading health concerns,
including malnutrition and malaria, will remain so
unless concerted action is taken to reduce their
toll. But perhaps the greatest challenge to public
health will be to reduce the impact of the two
great public health pandemics of the late 20th
century, tobacco and HIV.
Murray CJL and Lopez AD (eds) (1996) The
Global Burden of Disease. The Harvard School
of Public Health on behalf of the WHO and the
World Bank, Harvard University Press, Boston.
Murray CJL and Lopez AD (1997) Global
mortality, disability, and the contribution of risk
factors: Global Burden of Disease Study. Lancet
Nevin Scrimshaw (UNU): In the 1960s, there was
the PAHO study by Serrano and Puffer, and
more recently the study by Pelletier of Cornell
University, indicating that when one looked at
deaths from infectious diseases in developing
countries, nutrition was a major contributing
factor in about half of them. The contribution of
malnutrition to mortality was missed in the official
vital statistics. We had similar findings on a
smaller scale in an INCAP study in four villages.
How can you take into account nutrition as a
major contributory factor to deaths when it is not
Alan Lopez: In fact, that is Part 3 of the Study. It
is a very interesting issue that applies not only to
nutrition, but also, for example, to diabetes. I
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
didn't even mention today that diabetes is an
outcome and also a risk factor for several major
vascular conditions. In this study we looked at
malnutrition— undernutrition, to be more
specific— as a risk factor for this host of
conditions. We did not try to quantify how it
came out individually according to disease, but
rather how malnutrition contributed to the burden
of disease across a host of conditions. Those
are the estimates that I've tried to present. I
don't know whether they're right. This is the kind
of community that should be providing input back
to us saying that they're either over- or underestimates. Malnutrition is considered in the
same way as, for example, war, as a risk factor.
I've presented results from war as an outcome,
but war also could be looked at as a risk factor
because it causes a host of conditions in
health— not just the outcome of death or
disability as a war-related event.
Aileen Robertson (WHO): I'm glad that you
qualified the term "malnutrition" by saying
"undernutrition" since clearly unhealthy nutrition
and excessive intake of nutrients also contribute
to the burden of disease. In your paper you
predict that there will be a 77% increase in noncommunicable diseases. You go on to say that
the burden of disease of NCD is largely driven by
population ageing and tobacco with no mention
of nutrition. I feel that this is a lost opportunity for
improving public health. On the one hand, you
say that the major killers are NCDs and on the
other, you state that "malnutrition" has zero
effect. Clearly this is not the case and is
misleading policy makers responsible for public
health strategies. In the Former Soviet Union and
in Europe, unhealthy nutrition is one of the major
causes of NCDs, therefore, your "burden of
disease" model does not help to convince policy
makers of this fact. Your approach is a major
obstacle to getting nutrition on the political
agenda. I don't know what can be done to
address this problem. The question is do we
have to wait for the next proposed set of DALYs
before this error can be corrected?
Alan Lopez: That is also a very good issue and
thank you for raising it. More broadly in Europe,
there is a tremendous public health problem that
we are not quantifying very reliably. We don't
know, to my knowledge, reliably what is the
contribution of overnutrition or poor nutrition in
Central and Eastern Europe, nor indeed, do we
know about alcohol. There is suspicion that a lot
of this rise in mortality is due to alcohol, but we
don't know reliably. I feel that issues such as this,
that are major public health problems, need to be
more reliably quantified. I'm not saying that we
got it all right— this was a global, macro-regional
study. Within the macro-region (of the Former
Socialist Economies of Europe, FSE), we've
attributed virtually no DALYs to poor nutrition,
and that clearly is not correct.
Urban Jonsson (UNICEF): Your presentation
consisted of two major parts: mortality analysis,
and this other meta-physical concept of DALYs.
The mortality analysis I fully accept and I think
that most of your sensible conclusions could
have been shown with conventional mortality
analysis. There is one thing that we are sure
about— that we will all die one day. Many people
don't care what they die of if they live long, but
we are all concerned about young people
dying— in particular, children. There is no
scientific method to assess the value associated
with living longer. In the theory of science, we
separate between science and meta-physics.
Why do we do that? We do that to avoid the type
of thing that we have seen here, because the
DALY concept fulfils all the criteria for metaphysics. There are basically too many value
The method that you have
designed only says that you believe that average
is right. It would be a terrible society if we
believed that. Also, in the rank theory that you
use, you know very well that it doesn't matter that
much where the convergence of value judgement
comes— you get the same picture. I know for
example, people in wheelchairs who tell me that
their life is actually richer after their accident.
How do you account for all these complexities?
How can we predict things this way? If your
model had been used in 1985 for the Soviet
Union— would it have predicted the break down
of the Soviet Union and predicted these
Finally, from a human rights
perspective, the right of people to be healthy and
alive tells me that this type of analysis is
fundamentally not only unscientific, but is totally
Chapter 8: Gender and Nutrition in the Global Burden of Disease, 1990 to 2020
Graeme Clugston (WHO): I must say that your
transparency about the uncertainties is
appreciated. You mentioned about 40 countries
that have used this methodology in some way for
readjusting priorities, or spending, or adjusting
their emphasis on public health policy. Could
you say a little more about that? Have you in
any way been able to look at the changes that
they've brought about as a result of using this
methodology? Concerning the huge growing
problem of obesity in children and adults, the
Nutrition Programme at WHO has a growing
global database on body mass index for both
children and adults, which we would like to share
with you.
Alan Lopez: Let me deal with those questions in
reverse order. I have not been that involved in
the country studies. That is not something that
WHO has been particularly concerned with. We
were involved in the global and regional part
only. Most of the country studies have been
done at Harvard. There are around 40 studies
that are either completed, or are being carried
out, or are planned. In the studies that have
been completed, for example, in Mexico, it was
found that the health information system was
completely inadequate.
They were not
quantifying or measuring disability in any way
that was useful. They were not even using the
cross-sectional disability data that they were
collecting. They did find, however, that it was
going to be helpful if they applied this longitudinal
concept. They also found that a lot of their
cause-of-death information for violence was
being miscoded. What burden of disease
methods do is make you go into your data
system and be critical about how you're capturing
various conditions. In terms of public health
policy in Mexico, they have now established a
public health foundation that they are using to try
and address some of the inequities that I very
quickly showed.
Coming back to the other issue, it is important
that we are very clear what DALYs are and what
DALYs are not. We could debate these kinds of
questions for a long time, but I will be very brief.
If you do not try to quantify non-fatal outcomes,
you will perpetuate the omission of issues such
as the neuro-psychiatric conditions, maternal
anaemia and all of those leading causes of
disability that we found in our study. The idea
was that we tried to present to health care
providers and those responsible for health care
allocation, a holistic view not only of who dies of
what, but of who is disabled and from what.
Annex to Gender and Nutrition in the Global Burden
of Disease, 1990 to 2020
By Christopher Murray and Alan Lopez
Defining a Metric to Measure Disease Burden
In order to capture the impact of both premature
death and disability in a single measure, a
common currency is required. Time is an
appropriate currency, measured as time (in
years) lost through premature death, and time (in
years) lived with a disability. A range of such
time-based measures has been developed in
different countries, many of them variants of the
so-called Quality-Adjusted Life Year or QALY.
For the GBD, an internationally standardised
form of the QALY has been developed, called the
Disability-Adjusted Life Year (DALY). The DALY
expresses years of life lost to premature death
and years lived with a disability of specified
severity and duration. One DALY is thus one lost
year of healthy life. Here, a �premature’death is
defined as one that occurs before the age to
which the dying person could have expected to
survive if they were a member of a model
population with a life expectancy at birth equal to
that of the world’s longest-surviving populations,
namely Japan.
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
To calculate total DALYs for a given condition in
a population, years of life lost (YLLs) and years
lived with disability of known severity and
duration (YLDs) for that condition must each be
estimated, and then the total summed. For
example, to calculate DALYs incurred through
road traffic accidents in India in 1990, the total
years of life lost in fatal road accidents are added
to the total years of life lived with disabilities by
survivors of such accidents.
It might appear that quantifying disease burden is
a neutral exercise, entirely free of value choices.
However, this is far from the case. Disease
burden is, in effect, the gap between a
population’s actual health status and some
�ideal’, or reference status. In order to measure
burden, a society has to decide what the ideal or
reference status should be. This involves
making five value choices:
How long �should’ people live? If one is to
estimate how many years of life are lost
through death at any given age, we must
decide on the number of years for which a
person at that age should expect to survive
in the ideal, or reference, population. That
could be, for example, 60, 80, or 90 years
from birth.
Are years of healthy life worth more in young
adulthood than in early or late life?
Is a year of healthy life now worth more to
society than a year of healthy life in 30
Are all people equal? For example, should
one socioeconomic group’s years of healthy
life count for more than another’s?
How do you compare years of life lost due to
premature death and years of life lived with
disabilities of differing severity?
In accordance with the GBD’s egalitarian
principles, the study assumes a standard life
table for all populations, with life expectancies at
birth fixed at 82.5 years for women and 80 years
for men. A standard life expectancy allows
deaths in all communities at the same age to
contribute equally to the burden of disease.
Alternatives, such as using different life
expectancies for different populations that more
closely match their actual life expectancies, are
inconsistent with the egalitarian principle. For
example, if a 25-year-old woman dies in
childbirth in an African country where she might
have expected to live another 30 years, her
years of life lost would be deemed unfairly to be
fewer than those for a 35-year-old woman who
dies in childbirth in Japan, when she might
otherwise have expected to live another 48
Life expectancy is not equal for men and women.
Accordingly, the GBD has given men a lower
reference life expectancy (80 years) than that of
women (82.5 years).
If individuals are forced to choose between
saving a year of life for a 2-year-old and saving it
for a 22-year-old, most prefer to save the 22year-old. A range of studies confirms this broad
social preference to �weight’ the value of a year
lived by a young adult more heavily than one
lived by a very young child or an older adult.
Adults are widely perceived to play a critical role
in the family, community, and society. We
therefore incorporated age-weighting into the
DALY by assuming that the relative value of a
year of life rises rapidly from zero at birth to a
peak in the early twenties, after which it steadily
If a person is offered $100 today or $100 in a
year’s time, that person is likely to prefer $100
today. Future dollars are thus discounted—
valued lower— against current dollars. Whether
a year of healthy life, like a dollar, is also deemed
to be preferable now rather than later, is a matter
of intense debate among economists, medical
ethicists, and public health planners, because
discounting future health affects both
measurements of disease burden and estimates
of the cost effectiveness of an intervention.
There are arguments for and against discounting.
We decided, however, to discount future life
years by 3% per year. This means that a year of
healthy life bought for 10 years hence is worth
around 24% less than one bought for now, as
Chapter 8: Gender and Nutrition in the Global Burden of Disease, 1990 to 2020
discounting is represented as an exponential
decay function.
Discounting future health reduces the relative
impact of a child death compared with an adult
death. For example, with age-weighting also
incorporated, a 1-year-old girl’s death causes a
loss of 34 years of life while a 25-year-old
woman’s death results in a loss of 33 years of
life. Discounting also reduces the value of
interventions that pay off largely in the future—
such as vaccinating against hepatitis B, which
may prevent thousands of cases of liver cancer,
but only some decades later.
While death is not difficult to define, disability is.
All non-fatal health outcomes of disease are
different from each other in their causes, nature,
and their impact on the individual, and the impact
on the individual is in turn mediated by the way
the surrounding community responds. Yet, in
order to quantify time lived with a non-fatal health
outcome and assess disabilities in a way that will
help to inform health policy, disability must be
defined, measured, and valued in a clear
framework that inevitably involves simplifying
There is surprisingly wide agreement between
cultures on what constitutes a severe or a mild
disability. For example, a year lived with
blindness appears to most people to be a more
severe disability than a year lived with watery
diarrhoea, while quadriplegia is regarded as
more severe than blindness. These judgements
must be made formal and explicit if they are to be
incorporated into measurements of disease
Two methods are commonly used to formalise
social preferences for different states of health.
Both involve asking people to make judgements
about the trade-off between quantity and quality
of life. This can be expressed as a trade-off in
time (how many years lived with a given disability
would you trade for a fixed period of perfect
health?) or a trade-off between persons (would
you prefer to save one life-year for 1000 perfectly
healthy individuals as opposed to saving one lifeyear for 2000 individuals in a worse health
state?). While such trade-offs may affront our
perceptions about what is morally acceptable,
they are practised implicitly throughout the
world’s health care system. The philosophy of
the GBD is that the more explicitly these
preferences are set out, the more meaningfully
they may be debated.
The GBD therefore developed a protocol based
on the person trade-off method. In a formal
exercise involving health workers from all regions
of the world, the severity of a set of 22 indicator
disabling conditions— such as blindness,
depression, and conditions that cause pain— was
weighted between 0 (perfect health) and 1
(equivalent to death). These weights were then
grouped into seven classes where class I has a
weight between 0.00 and 0.02 and Class VII a
weight between 0.7 and 1 (see Table 12).
In essence, the weight is set by the number of
people with a given condition whose claim on a
fixed health care budget is equal, in the
judgement of a participant, to that of 1000
entirely healthy people. For example, if the
participant judges that 1000 entirely healthy
people were judged to have an equal claim on
the resources as 2000 people with a particular,
less severe, disability, the weight assigned would
be equal to 1 minus 1000 divided by 2000, or
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Table 12: Gauging the severity of disability: disability classes and weights
set by the GBD protocol for 22 indicator conditions
Indicator conditions
Vitiligo on face, weight-for-height less than 2 standard deviations
Watery diarrhoea, severe sore throat, severe anaemia
Radius fracture in a stiff cast, infertility, erectile dysfunction, rheumatoid
arthritis, angina
Below-the-knee amputation, deafness
Recto vaginal fistula, mild mental
retardation, Down’s syndrome
Unipolar major depression, blindness, paraplegia
Active psychosis, dementia, severe migraine, quadriplegia
Note: These weights were established using the person trade-off method with an international group of health workers who met at
WHO in Geneva in August 1995. Each condition is actually a detailed case. For example, angina in this exercise is defined as
reproducible chest pain, when walking 50 metres of more, that the individual would rate as a 5 on a subjective pain scale from 0 to
Chapter 9: The Abraham Horwitz Lecture. Breastfeeding: From Biology to Policy
Chapter 9
The Second Abraham Horwitz Lecture, 1998
Breastfeeding: from Biology to Policy
Isatou Jallow Semega-Janneh
Introductory paragraphs by Richard Jolly,
SCN Chairman
The Abraham Horwitz Lecture was first
introduced last year in honour of Dr Abraham
Horwitz, who was Assistant Director of the
National Health Service in Chile from 1953-59,
Director of the Pan American Health
Organization (PAHO) from 1959-1975, and
Chairman of the SCN from 1986-1995. Dr
Horwitz is currently Director Emeritus of PAHO.
The Lecture was established in recognition of Dr
Horwitz’ outstanding contribution to nutrition and
his exemplary leadership as our Chairman. The
intention of the Lecture is to promote Dr Horwitz’
heartfelt, highly valued and extremely generous
tradition of mentoring young talent from
developing countries. Each year a guest
lecturer, who possesses the knowledge and
commitment to prepare a bold and imaginative
paper, is invited to make a presentation at the
SCN Session. Our lecturer today is Isatou Jallow
Semega-Janneh. We reviewed eight possible
candidates for this Lecture in order to find
someone who has shown true leadership at an
early stage of their career. Isatou Jallow
Semega-Janneh is currently the head of the
Nutrition Unit of the Department of State for
Health, Social Welfare and Women’s Affairs in
Banjul, The Gambia. She also chairs the Board
of Directors for The Gambia Food and Nutrition
Association and is national breastfeeding
coordinator in The Gambia. She has an MSc
(1986) in Nutrition from the University of Oslo in
Norway. But the main reason we selected her
was that she was by all accounts an up-andcoming dynamic leader with much involvement in
community work. We are very pleased therefore
that Isatou Jallow Semega-Janneh, you have
been able to accept our invitation.
I feel privileged and honoured to be here today to
talk on such an important topic as breastfeeding.
I am here not as an expert but as a woman,
mother, and a health worker in a nonindustrialised country. Some may well question
why breastfeeding should merit this attention
when it is the simple and natural way of feeding
our young. However, it is this very simplistic
view of breastfeeding that may cause some to
take it for granted and to consider breastfeeding
promotion a waste of resources �since women
breastfeed anyway’. Yet, statistics indicate that
most mothers do not practice optimal
breastfeeding1 and exclusive breastfeeding—
defined by WHO as giving no other food or
liquids including water to the infant for up to 6
months of age— is a rare practice. It is estimated
that almost 1.5 million infant lives could be saved
per year if exclusive breastfeeding was practised
for the first 6 months (UNICEF, 1997a).
Breastfeeding promotion has come a long way
over the decades, and this is mostly due to the
high profile it has been given through
This is defined as exclusive breastfeeding from birth to
about 6 months of age. Thereafter, children should continue
to be breastfed while receiving appropriate and adequate
complementary foods for up to 2 years of age or beyond.
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
international level commitment 2. In reference to
the dangers of artificial feeding, Dr Cecily
Williams spoke of �Milk and Murder’ as far back
as 1939. La Leche League formed the first
organised breastfeeding group in 1957, which
has since grown to over 40,000 members.
During the 1970s, attention was focused on
breastfeeding through campaigns, including
lawsuits to stop the aggressive promotion of
infant formula to the detriment of breastfeeding.
The International Baby Food Action Network
(IBFAN) was founded in 1979— the same year
that WHO and UNICEF hosted an international
meeting on infant and young child feeding. The
meeting called for the development of an
International Code of Marketing of Breastmilk
Substitutes, which was later adopted at the
World Health Assembly in 1981. There have
been various World Health Assembly resolutions
thereafter on infant and young child feeding.
The Convention on the Rights of the Child was
adopted in 1989 and came into legal force in
1990. It referred to �all segments of society, in
particular parents and children being informed,
having access to education and being supported
in the use of basic knowledge of child health and
nutrition, and the advantages of breastfeeding… .’
The Innocenti Declaration on the Protection,
Promotion and Support of Breastfeeding was
developed and adopted in 1990. It set specific
goals for all governments to be achieved by the
year 1995, as well as soliciting the support of
international organisations. The Declaration
called for the integration of breastfeeding policies
into the overall health and development plans of
governments. It also emphasised the need to
increase women’s confidence in their ability to
breastfeed, which should involve the removal of
barriers to optimal breastfeeding. This
Declaration was adopted by 32 governments and
10 UN agencies.
The World Summit for Children was held in 1990
and one of its goals was the �empowerment of all
women to breastfeed their children exclusively
for 4-6 months and to continue breastfeeding
See AHRTAG Resource List: Breastfeeding Information
Resources; published by Appropriate Health Resources and
Technologies Action Group (AHRTAG), London UK.
with complementary food, well into the second
Individuals and organisations dedicated to the
protection, promotion, and support of
breastfeeding formed an umbrella network—
World Alliance for Breastfeeding Action (WABA)
in 1991. During this same year, UNICEF/WHO
launched the global Baby Friendly Hospital
Initiative aimed at creating breastfeeding friendly
environments at health facilities. The
International Conference on Nutrition (ICN) in
1992 showed tremendous commitment to
breastfeeding by incorporating it in most of its
themes as well as in the World Declaration and
Plan of Action for Nutrition .
The Biology of Breastfeeding
It has been a popular belief that breastfeeding
benefits mostly non-industrialised countries
because breastmilk is a clean, �cheap’ food in
light of inadequate resources and poor sanitary
conditions. Today we know differently as
research continues to show its benefits for both
industrialised and non-industrialised countries.
This literature is reviewed by Dermer (1998) for
women’s health issues and Villapando and
Hamosh (1998) for the infant.
In discussing the health benefits of
breastfeeding, the emphasis is usually on the
infant. Breastfeeding, however, is not a private
matter between the breasts and the infant as can
be misconstrued from pictures of infants feeding
from �faceless’ breasts. Breastfeeding is a
process that involves two individuals: the mother
or the �breastfeeder’ as the producer, and the
infant as the consumer. The process benefits
both the producer and the consumer and this is
very important to highlight in breastfeeding
promotion programmes. It is also crucial for the
breastfeeding mother to know this.
Future research might yet discover further
benefits of breastfeeding for both a mother and
her infant. It is time for women to recognise the
importance, the uniqueness, and value of their
breasts. Maybe it is also time for women to start
insuring these extremely valuable assets— their
Chapter 9: The Abraham Horwitz Lecture. Breastfeeding: From Biology to Policy
Box 5: Breastfeeding: benefits for the mother
Breastfeeding helps the uterus to return more quickly to its original size and thus minimises postpartum bleeding.
This reduces the risk of anaemia for the breastfeeding mother and may contribute to a reduction in maternal
Breastfeeding reduces the risk of premenopausal breast cancer and ovarian cancer.
Breastfeeding is associated with improved bone remineralisation.
Breastfeeding causes mothers to return more quickly to their pre-pregnancy weight.
Breastfeeding has child spacing benefits and prevents more births in Africa and many parts of Asia than
contraception. The Bellagio Consensus Conference in Italy in 1988 agreed that the Lactational Ammenorrhea
Method (LAM) gives about 98% protection from pregnancy during the first 6 months after delivery if the mother is
fully or nearly fully breastfeeding, and remains ammenorrheic during that period (Consensus Statement, Lancet,
1988). The efficacy of LAM was demonstrated in a clinical case control intervention study. The contribution to
child spacing of the traditional practice of sexual abstinence during the breastfeeding period still practised today,
should not be underestimated.
Breastfeeding has emotional and psychological benefits, which are very important elements of maternal and child
health. Examples of these are the satisfaction and the confidence of the mother in her capability to nurture her
infant in the best possible way. This also includes the emotional bonding between the breastfeeding mother and
her infant.
The full benefits of breastfeeding may, however,
not be realised if optimal breastfeeding,
including exclusive breastfeeding,
is not practised.
Box 6: Breastfeeding: benefits for the infant
Breastfeeding reduces the severity and incidence of diarrhoea during the first year, which is one of the major
causes of mortality among infants and young children in developing countries.
Breastfeeding reduces the risk of lower respiratory infections, otitis media, atopic disease and necrotising
Breastfeeding may protect against insulin-dependent diabetes mellitus and urinary tract infections.
Breastfeeding may protect infants from the sudden infant death syndrome as well as from chronic digestive
diseases, Crohns disease and ulcerative colitis and lymphoma.
Breastfeeding improves the infant's neurological development.
Breastfeeding may reduce the risk of bacterial meningitis and bacteremia. Breastfeeding stimulates the infant's
immune system.
Breastfeeding may reduce the risk of heart disease in later life.
Breastfed infants show a better response to vaccines while being protected against hay fever and asthma for up to
17 years.
Global Patterns
Despite documented evidence of its benefits,
global estimates indicate that 85% of mothers do
not conform to optimal breastfeeding practices
(see Obermeyer and Castle, 1997). Exclusive
breastfeeding is still rare in a number of countries
(Labbok et al., 1997). Estimates from the WHO
Global Data Bank (1996), indicate that only 35%
of infants have been exclusively breastfed for
some duration during the first four months of life
(see Table 13). These alarmingly low figures on
exclusive breastfeeding are, however, usually
hidden under high initiation rates and long
duration of breastfeeding as in the example from
the African region where the median
breastfeeding duration is 21 months.
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Table 13: Exclusive breastfeeding and median duration of breastfeeding:
a global and regional overview, 1996
WHO Region
of infants
number of
Number of
countries in
the Region
included (%) a
Percentage of
Infants in the
rate <4 months
of age (%)c
duration of
The Americas
South-East Asia
25 (54)
14 (40)
5 (50)
4 (8)
11 (50)
Western Pacific
2 (7)
World total
61 (32)
Countries for which nationally representative data are available.
Percentage of children less than one year of age by region for which nationally representative data are available.
c Percentage of infants under four months of age whose sole source of nourishment is breastmilk the day before the interview.
Source: WHO Global Data Bank on Breastfeeding
Barriers to Optimal Breastfeeding
The fact that exclusive breastfeeding is practised
by a minority of women may be attributed to a
number of factors. Among these are cultural,
social, economic, and political factors.
Cultural factors may be crucial when promoting
exclusive breastfeeding everywhere, but are
particularly crucial in traditional rural
Local perceptions of what
constitutes optimal infant feeding practices may
recommendations. Globally, prelacteal feeding is
a common practice that includes giving the infant
various liquids, as well as water, prior to initiation
of breastfeeding (Morse et al., 1990) and
continuing throughout the duration of the
breastfeeding period.
Davies-Adetugbo (1997), in a recent study on
socio-cultural factors and the promotion of
exclusive breastfeeding in rural communities,
concluded that exclusive breastfeeding totally
lacked credibility among the locals, with even
health workers not believing that it was possible
or feasible. Therefore promotion of optimal
breastfeeding practices, including exclusive
breastfeeding, cannot be successful if the
cultural barrier is not adequately addressed.
Exclusive breastfeeding for up to 6 months
requires the mother and her infant to be in close
proximity for this period and to use expressed
breastmilk for separation of short duration.
However, practising exclusive breastfeeding may
be perceived as being non-compatible with
working outside of the home, thus creating an
economical barrier. This includes mothers
working both in the formal and informal sector.
This notion may be viewed from two angles.
Firstly, from that of the employer, including
governments, who may wrongly perceive that the
provision of adequate maternity leave,
breastfeeding breaks, and crГЁches at the work
place would result in losses rather than profits.
Secondly, from that of the mother, who may
believe that practising exclusive breastfeeding
would limit the time she has for other activities—
especially income-generating activities.
A sick infant results in a worried mother, which in
turn may result in a less productive mother.
Absenteeism from work due to a sick infant may
have more economical consequences than
adequate maternity protection measures for
optimal breastfeeding.
The lack of social support systems at the
household and community levels are also a
Chapter 9: The Abraham Horwitz Lecture. Breastfeeding: From Biology to Policy
barrier to optimal breastfeeding. Mothers require
an enabling environment if they are to practice
optimal breastfeeding and this can only be
possible with full support at both the household
and the community levels. The issues to be
addressed include the workload of the pregnant
and lactating woman, among others.
National policies on breastfeeding are important
for the promotion and support of breastfeeding at
all levels. The lack of political commitment to
breastfeeding promotion and support may be due
to ignorance of its many benefits for the
individual (mother and infant), household,
community, and the nation. Governments have
still to understand the health, social, and
economic benefits of breastfeeding.
In light of all the barriers outlined above, how can
we successfully get mothers to practice optimal
breastfeeding, including exclusive breastfeeding?
Breaking the Barriers with the Baby Friendly
Community Initiative— The Gambia
I will now give an example of attempts we have
made in The Gambia to break some of these
barriers through a Baby Friendly Community
Initiative (BFCI) project. Breastfeeding is a
universal practice in The Gambia but exclusive
breastfeeding is rare and weaning foods are
introduced by the age of 3 months. In 1993, the
Nutrition Unit of the Department of State for
Health initiated a pilot project— the Baby Friendly
Community Initiative.
The concept of a
community initiative was derived from the global
UNICEF/WHO Baby Friendly Hospital Initiative
(BFHI) of 1991.
This involved 12 rural
communities in the Lower River Division of The
The rationale behind the community initiative was
that most deliveries in The Gambia occurred at
home, and those women who delivered at health
facilities only stayed there for a day or less with a
normal delivery. The way mothers fed their
infants therefore was influenced to a greater
extent by the traditional beliefs and practices in
their home environment.
The aim of the BFCI was to improve infant
feeding practices in rural Gambia. Among the
objectives were:
to get 25% of mothers to practice exclusive
breastfeeding for at least 4 months;
to get 90% of mothers with normal delivery
to initiate breastfeeding within an hour of
A baseline study was carried out using
quantitative and qualitative methods. The aim
was to identify current infant feeding practices,
including the traditional beliefs and practices
influencing them. All mothers with infants 0-12
months were included in the study (n=324).
Results from this baseline study indicated suboptimal feeding practices.
A methodology using an integrated approach
was developed for the intervention. This
included �10 steps to successful infant feeding’,
based on the Baby Friendly Hospital Initiative �10
steps’ (WHO, 1989). However, the community
initiative went beyond breastfeeding to include
maternal nutrition (using locally available foods),
weaning, environmental sanitation, and personal
hygiene. This integrated approach was important
so as to emphasise the linkages between
maternal and infant nutrition, and a clean
environment. It was expected that this approach
would also create the opportunity for maximum
community participation in the project.
The 10th step of the Baby Friendly Hospital
Initiative was used as a basis for the creation of
�village support groups’. In this instance, motherto-mother support groups (Kyenkya-Isabirye and
Magalhaes, 1990) took on a new meaning with
the inclusion of men in the groups. A village
support group consisted of five women and two
men— identified by their communities— to be
trained to implement and monitor the initiative.
Among them was the traditional birth attendant
whose role in the project was crucial because
she delivered babies in her community. Support
group members were aware from the outset that
they were voluntary and did not expect any
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
A guide was developed for training the village
support groups. It was divided into sessions
ranging from maternal and infant nutrition, to
environmental sanitation and personal hygiene,
using material from WHO, UNICEF, and
Wellstart International. In the training, the
participants were viewed from a dual
perspective; first as a target for attitudinal
change, and second as educators for their
communities. In this regard, therefore, the
training had a dual objective: to influence the
attitude of the participants, and to equip them
with relevant and adequate information for their
role as educators.
How does one attempt to influence the attitude of
a target person within a limited period? First of
all, it is by acknowledging that the targets have
their own local knowledge, which probably differs
from our knowledge. To disregard this local
knowledge could be detrimental to the
achievement of the project objectives.
This meant that participants were given the
opportunity to discuss a topic, e.g. colostrum,
based first on their local traditional knowledge.
The topic was then presented by the trainer
using modern scientific knowledge. Finally
participants were again given the opportunity to
question, argue, and gradually understand the
topic from their own perspective. This gave us
the following equation:
Modern / Scientific Knowledge + Local /
Traditional Knowledge = Credible Knowledge
One example of how this equation worked is the
understanding of the concept of exclusive
breastfeeding by the participants.
prelacteal feeds as well as water and other
liquids throughout the breastfeeding duration was
considered the norm. Therefore, exclusive
breastfeeding was a modern concept that participants could not accept. However, through
discussions, participants recalled that their newborn animals (livestock)3 breastfed only without
drinking any water for an unspecified period, yet
they did not die. Based on this reasoning, the
The Gambia is predominantly an agricultural society
practice of exclusive breastfeeding seemed
credible for human babies.
Apart from theoretical information, the training
emphasised practical solutions to simple problems that breastfeeding mothers may encounter.
These included cracked or sore nipples and
engorged breasts for which avoidable causes
and simple solutions were identified. It was
expected that such practical information would
make the support groups more persuasive and
credible in their communities.
The support groups were also taught about
breastmilk expression for mothers who had to be
away from their infants for short periods. There
was some initial reluctance to this based on their
belief that breastmilk can turn sour if not utilised
for several hours. Even mothers who are away
from their babies for a few hours, according to
local tradition, were expected to express and
throw away the first milk before breastfeeding.
Men are important actors in infant feeding decisions but are not usually targeted by breastfeeding intervention programmes. Their involvement
in this initiative, as both information providers
and information recipients, was a formal
acknowledgement of the important role they play.
It was also one step further to achieving the objectives of the BFCI. Mothers alone may find it
difficult to take a decision on exclusive breastfeeding without the support of their husbands.
With men as members of the support group, it
was also assumed that it would be easier to
convince their fellow men as well as to support
their wives.
Almost all the participants were non-literate but a
graduation ceremony after the training with certificates issued to all the participants proved to be
highly motivating. The ceremony, involving senior officials from the Health Ministry and other
government institutions and NGOs, was a sign of
government support and acknowledgement of
their participation in the project.
There was regular monitoring and retraining of
the support groups by the Nutrition Unit.
According to the group members, these activities
not only strengthened the groups, they also
served to motivate them.
Chapter 9: The Abraham Horwitz Lecture. Breastfeeding: From Biology to Policy
Target groups were specified by the project as
pregnant and lactating women and their spouses.
How information was disseminated in the
communities was left entirely to the village
support groups. The support groups were very
innovative. They used house-to-house visits,
village gatherings, ceremonies, songs, dances,
and role-plays to disseminate information. The
�10 steps’were made into songs and were sung
at every opportunity thereby enabling even small
children to learn about breastfeeding and its
importance. Some communities expanded their
target groups to include schools, where they
gave talks and choreographed plays by the
The practice of exclusive breastfeeding became
universal as a result of the project. This was
somewhat unexpected, given the scepticism
voiced by some individuals in the communities.
Breastfeeding was initiated within one hour of
delivery by 87% of mothers after the intervention.
A full 99.8% initiated within 24 hours of delivery.
This can be compared to 40% initiation later than
24 hours following delivery before the
The duration of exclusive
breastfeeding also increased considerably. After
the intervention 99.5% of mothers (n=413) fed
only breastmilk at four months of age as opposed
to only 1.3% before the intervention (n=324).
Attitudinal change was evident from the way in
which colostrum was referred to. Before the
intervention, colostrum was referred to as bad
milk, dark milk or hot milk. After the intervention,
colostrum was referred to as the protective
milk. Furthermore, exclusive breastfeeding did
not have a local name before the intervention
and was regarded as a foreign concept. During
the intervention, a new term in Mandinka was
coined— susundiri timaringo— which translates
literally as the �complete breastfeeding’, and this
became a password in the communities.
The unifying effect of the project on community
members was another unexpected outcome of
the BFCI. Optimal breastfeeding became the
concern of both mother and father, while
adequate maternal nutrition became the concern
of wife and husband. Environmental sanitation
involved the whole community resulting in regular
village clean-up.
Awareness of the importance of an enabling
environment for breastfeeding mothers was
raised through this initiative. This is defined as
any activity that enhances the mother's capacity
to practice optimal breastfeeding, specifically
exclusive breastfeeding. Rural women farmers,
however, may face similar constraints as their
counterparts in the formal sector (Saadeh et al.,
1993) with regards to inadequate day care
facilities at the workplace. During discussions
with the communities, it was learnt that the
mothers in this project were no exception.
Traditional shelters at the fields, which had been
used to protect infants from various weather
conditions no longer existed in most of these
communities. Consequently, the concept of a
�Baby Friendly Rest House’at the field, was born
as a by-product of the traditional shelters and the
modern crГЁches. Eight communities opted for
them and mobilised both men and women to
construct them.
A �community maternity leave’concept was also
derived from the example of a 12-week
government maternity leave and the traditional
40 days rest for new mothers. This involved
community assistance for the breastfeeding
mother at her farm and while she stayed home
with her infant, for a period of up to six months or
more. It was adopted unilaterally by one
community while the remaining communities
chose to have it as an option for individual
Expressing and storing breastmilk for the infant—
previously considered an undesirable practice—
was now done by mothers who had been
convinced by support group members. This
practice was widely adopted by mothers who had
to be away from their infants. The expressed
milk was often stored at the foot of their clay
water jars, which was believed to be the coolest
place in the house. All the above contributed to
an enabling environment for rural mothers to
practice exclusive breastfeeding for up to six
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Policy Issues
The success of the BFCI pilot project resulted in
it being recommended for expansion nationally
within the next five years (The Gambia Health
Action Plan 1999-2003). The cost implications of
the expansion are limited mostly to the training,
retraining and evaluation of the village support
groups. There are no external resources
required for the dissemination of information by
the support groups. They decide how and when
to disseminate information. The cost to them is
their time, which they are willing to give by
accepting the nomination from their communities.
A motivating factor, however, is the status
attached to being pioneers of a community
initiative, adapted from a global initiative.
The Gambian example shows the importance of
maternity protection measures for all working
mothers whether in the formal or informal sector.
These measures include adequate maternity
leave, nursing breaks and crГЁches at
workplaces. In some countries, paternity leave is
an option for fathers, giving them the opportunity
to provide support for the mother and her infant
from the beginning.
The ILO’s Convention No. 3 from 1919,
recommended at least 12 weeks maternity leave
for women in commerce and industry. The
updated version from 1952, Convention No. 103,
was expanded to include coverage for nonindustrial and agricultural workers, including
women wage earners working at home.4
However, this did not really change anything,
since Article 7 in the same Convention (103)
gave countries the option not to include these
categories of workers. Moreover, the Convention
was ratified by only 33 countries.
The Convention on the Elimination of all Forms
of Discrimination Against Women (CEDAW) from
1979 also called for maternity protection and was
ratified by 146 countries as of October 1994.
Yet, maternity protection is still an issue that
needs to be addressed since in most countries it
See Women’s Rights to Maternity Protection, Information
for Action by The American Public Health Association
(APHA), Clearinghouse on Infant Feeding and Maternal
Nutrition; 1996
is either inadequate or women do not utilise it
fully through lack of information. There are still
some countries that do not satisfy even the
minimum requirement of 12 weeks paid maternity
leave. Other countries, e.g. Norway, far exceed
this requirement, with up to 52 weeks maternity
leave (80% benefits) which includes optional
paternity leave (UNICEF, 1997b).
Therefore, the call for governments through the
Innocenti Declaration (1990) to �enact
breastfeeding rights of working women and
establish means of its enforcement’, is still
relevant to most governments. It is, however,
encouraging to note that the ILO is now engaged
in a global review of maternity leave and will
hopefully do everything possible to encourage
governments, including the private sector, to pay
heed to the above call.
Most women around the world work outside of
the home but not in the formal sector. Many of
these women are engaged in farming activities.
While maternity protection should encompass all
women regardless of the type of work they are
doing, in reality, these women are excluded. Yet
they are advised to practice exclusive
breastfeeding for 6 months! Local communities
should be encouraged and assisted to find
solutions that are compatible with their traditional
beliefs and practices.
These should be
supported by national and local policies.
If the universal practice of optimal breastfeeding
is to be achieved, adequate and appropriate
information must be given at all levels of a
Information, however, is usually
targeted only at mothers and community health
workers. Each given situation must be assessed
to identify the barriers to optimal breastfeeding
and, in so doing, identify who needs what
information and why.
It is important to include all levels of health
workers as they can, in some cases, create the
biggest hindrance to optimal breastfeeding due
to conflicting information they give mothers. Men
need to also learn about breastfeeding to enable
Chapter 9: The Abraham Horwitz Lecture. Breastfeeding: From Biology to Policy
them to provide the necessary support and
encouragement for the mother and her infant.
Strategies to promote breastfeeding must not,
however, be limited to only technical information.
The self-perceptions and social relations of the
target person to be influenced must be taken into
consideration (Obermeyer and Castle, 1997).
Breastfeeding ensures adequate food and care
for the infant. The mother also needs special
care, and should be ensured the same. Care
during pregnancy and lactation should include
ensuring an adequate diet for the woman,
reducing her workload, and counselling her on
family planning options for adequate child
spacing. This would not only enhance the
mother's health but also her wellbeing. The
mother needs to feel that she is as important as
her infant!
Breastfeeding and breastmilk may seemingly be
under threat at the moment, with estimations
indicating a 14% additional risk of the HIV virus
being transmitted to the infant through breastmilk
(Dunn et al., 1992). This can be interpreted in
two ways depending on who is doing the
Firstly, for advocates of
breastfeeding the risk may seem small, and
options to further minimise this risk may be
sought. On the contrary, for those who would
benefit from the decrease in breastfeeding, this
risk could be exaggerated and instead used to
justify why women should not breastfeed.
All HIV-infected mothers should have the chance
to make an informed choice in the feeding of
their infants.
Therefore, infant feeding
recommendations for HIV-infected mothers
should consist of options. These must be clear,
specific, and concise. Examples are: heat
treatment of mother’s expressed breastmilk, the
traditional practice of wet nursing or expressed
breastmilk from a wet nurse, with the option of
feeding with artificial milk only where it is
affordable and safe. However, more urgent
efforts and resources need to be put into finding
solutions, which would not jeopardise the
breastfeeding of infants anywhere.
A Challenge to SCN Member Agencies
The rates of optimal breastfeeding from around
the world imply that national governments, even
though they make pledges and set targets in
international gatherings, make no real
commitment to breastfeeding in the form of
practical national policies and programmes. The
question therefore is: how can governments and
local communities be stimulated to accept
breastfeeding and breastmilk as being crucial for
the infant, mother, household, community and
Relatively simple and practical programmatic
interventions at the international level are
invariably reflected in national programmes. An
example of this is the UNICEF/WHO globallyadopted Baby Friendly Hospital Initiative
(UNICEF, 1997b). The challenge to SCN
member agencies, therefore, is to be more
aggressive through their specialised areas, to
literally bring home the importance and benefits
of breastfeeding to governments and their policy
Some suggestions are:
Due to its immunological properties, colostrum is
often referred to as �the first immunisation’. The
Expanded Programme on Immunization
therefore seems to be the obvious place to start.
According to the universal immunisation
schedule, BCG vaccine for the prevention of
tuberculosis and polio should be given at birth.
There is every reason for colostrum to be placed
on the same schedule to be given to the infant
immediately after delivery, and specifically, within
the first hour of delivery.
High immunisation coverage rates are often a
matter of pride for most governments in outlining
their achievements in the health sector. The
immunisation schedule is well known to health
workers and parents for most parts of the world.
In The Gambia for example, immunisation has
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
been found to be a motivating factor for regular
attendance at infant welfare and antenatal
This simple intervention would have a tremendous impact from the level of the policy maker to
the level of the mother and father. Imagine a
situation where health workers would no longer
refer to colostrum loosely as the first immunisation, but would actually be able to show evidence
of it on the schedule for the understanding of the
common person. The inclusion of colostrum on
the immunisation schedule would require very
little resources. Training of health workers on the
immunisation schedule should include a session
on the immunological and anti-infective properties of colostrum and the rationale for placing it in
the schedule.
Oral rehydration solution (ORS) is a simple solution that saves lives by preventing dehydration
due to diarrhoea. ORS is therefore on the WHO
list of essential drugs. Breastmilk is a more
complex liquid than ORS containing nutrients as
well as antibodies. Breastmilk saves millions of
lives of infants and young children. Given the
protective and life-saving properties of breastmilk, it becomes justifiable to include it on the
essential drug list alongside ORS. This would
serve to highlight and emphasise the status of
Breastmilk is a major source of food for nearly
3% of the world’s population i.e., over 140 million
infants born each year (Wellstart International,
1992). Therefore, breastmilk makes a substantial contribution to global and national food security. Yet despite attempts from as far back as the
1970s, there still seems to be a reluctance to
include breastmilk on global and national food
balance sheets!
Human milk production in Sub-Saharan Africa
has been estimated to equal 50% of the total
cow's milk produced in the region between 19911994 (Hatloy and Oshaug, 1997). What more
information or research findings are needed to
reconfirm breastmilk's importance to food
If breastmilk's contribution to global food security
were to be boldly acknowledged by the
responsible international agencies, then
governments could be requested and motivated
to do the same at the national level. Huge
investments are made by governments to
increase and improve food production as an
answer to food insecurity.
What is the
investment in breastmilk, perhaps the world’s
most basic and important food?
Breastmilk is a natural resource which, unlike
most other resources, is in global abundance
regardless of geographical location. But just like
most natural resources, governments have to
invest for their countries to benefit fully from it.
However, breastmilk is a marginalised resource
and is not explicitly ever considered by
governments as contributing to the national
What is the economic value of breastmilk and
how can one put a value on a combination of
nutrition, care, protection, and life-saving
qualities? Any economic value of breastmilk can
only be an underestimation. However, attempts
made to estimate the economical value (Levine
and Huffman, 1990) indicate substantial national
savings with breastfeeding. One study even
shows that this may increase a country's GNP by
more than 5% (as estimated for Mali: Hatloy and
Oshaug, 1997).
Healthier and happier mothers and infants
represent less private and public expenditure on
health care. Since most countries do not
manufacture infant formula but have to import it,
governments save foreign exchange by
encouraging the use of a natural resource, which
is also far superior to artificial milk.
It is time for international agencies supporting
economic-based interventions to include the
protection, promotion, and support of
breastfeeding. They should not only request but
also assist countries to establish the impact of
breastfeeding on national economies.
Chapter 9: The Abraham Horwitz Lecture. Breastfeeding: From Biology to Policy
In a time of dwindling resources, it makes perfect
sense for the world to make the optimal use of
one of its most sustainable natural resources—
breastmilk. Breastfeeding is the strongest
possible foundation for nutrition and care
(Armstrong, 1995). Breastfeeding is sustainable,
because breastmilk is naturally renewable as
well as vital to human development. Therefore,
plans of action for sustainable human
development should incorporate breastfeeding.
Tin plate, plastic, paper, glass, rubber, and
silicon are needed for the packaging of infant
milk formulae and the production of bottles and
teats. This requires resources, it also poses the
problem of waste disposal for some of these
items. It is estimated that if every baby in the
USA were bottle-fed, this would require 86,000
tons of tin plate to be used for manufacturing the
required 550 million baby milk tins (Radford,
Breastfeeding is environment friendly; yet how
many national environmental programmes have
included the promotion of breastfeeding in their
plan of action? If the global plan of action for the
preservation of the environment were to
incorporate breastfeeding promotion as one of its
strategies, this could be reflected in national
environmental action plans.
There is no dispute on the contribution of
breastfeeding to child spacing, which has been
known to mothers long before being confirmed
through scientific research (Short, 1992). Yet
the lactational ammenohrea method (LAM) as an
early form of family planning is not an option in
national family planning programmes except for a
committed few.
Who benefits, though, from breastfeeding being
downplayed as a family planning option?
Definitely, not the mother or her infant and, to
take it even further, not the nation— especially
one with limited resources, high fertility and low
literacy rates.
It is now long overdue for international agencies
concerned with population growth not only to
make a firm commitment in recognising
breastfeeding's contribution to global population
growth but to include breastfeeding as a family
planning option in their programmes. This
commitment could trickle down to national
population and family planning programmes.
Breastfeeding and breastmilk cut across all
boundaries. Regardless of race, colour, socioeconomic background, shape or size, the
process is the same and the product is basically
the same. Virtually all the major religions of the
world support and encourage breastfeeding
(UNICEF, 1994). Breastfeeding benefits the
mother and her infant in both industrialised and
non-industrialised countries.
In a recent editorial in the Lancet, it is rightly
stated that; �Policy makers need to understand
that provision of a warm chain for breastfeeding
is as valuable as provision of a cold chain for
vaccines and likewise requires adequate
resources. Governments and funding agencies
need to be convinced that the investment is
worthwhile’(Editorial, 1994).
While individual UN agencies have been
successful in focusing global attention on the
protection, promotion, and support of
breastfeeding, a central coordinating mechanism
within the UN system seems to be missing.
Such a mechanism, if put in place and given the
mandate, would no doubt maintain breastfeeding
high on the global and national agenda. Most
importantly, a central coordinating mechanism
would link breastfeeding with the relevant
programmes within the UN system.
Is there a role for the SCN in this?
Armstrong HC (1995) Breastfeeding as the
foundation of care. Food and Nutrition Bulletin
Consensus Statement (1988) Breastfeeding as a
family planning method. Lancet 2:1204-1205.
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Davies-Adetugbo AA (1997) Socio-cultural
factors and the promotion of exclusive
breastfeeding in rural Yoroba communities of
Osun State, Nigeria. Social Science and
Medicine 45:113-125.
Dermer A (1998) Breastfeeding and women’s
health. Journal of Women’s Health 7:427-433.
Dunn DT, Newell ML, Ades AE, Peckman CS
(1992) Risk of human immunodeficiency virus
type I transmission through breastfeeding.
Lancet 340:585-588.
Editorial (1994) A warm chain for breastfeeding.
Lancet 344(8932):1239-1240.
Hatloy A and Oshaug A (1997) Human milk: an
invisible food resource. Journal of Human
Lactation 13:299-305.
Innocenti Declaration on the Protection,
Promotion and Support of Breastfeeding, 1
August 1990, Florence, Italy. UNICEF, New
Kyenkya-Isabirye M and Magalhaes R (1990)
The mother support group role in the health care
system. International Journal of Gynecology &
Obstetrics 31, Suppl 1:85-90.
Labbok MH, Perez-Escamilla R, Peterson A,
Coly S (1997) Breastfeeding and child spacing
country profiles. Institute for Reproductive
Health, Washington, DC.
Levine R and Huffman S (1990) The Economic
Value of Breastfeeding, the National, Public
Sector, Hospital and Household Levels. A
Review of the Literature. Prepared for the Social
Sector Policy Analysis Project of the USAID
operated by the Academy for Educational
Development, Washington, DC.
Morse JM, Jehle C, Gamble D (1990) Initiating
breastfeeding: a world survey of the timing of
postpartum breastfeeding. International Journal
of Nursing Studies 27:303-313.
Obermeyer CM and Castle S (1997) Back to
nature? Historical and cross-cultural perspectives
on barriers to optimal breastfeeding. Medical
Anthropology 17:39-63.
Radford A (1992). The ecological impact of
bottle-feeding. Breastfeeding Review 2:204-208.
Saadeh R (ed) with Labbok M, Cooney K, KonizBooher P (1993) Breastfeeding: The Technical
Basis and Recommendations for Action.
Chapter 6, p93-102. WHO, Geneva.
Short R (1992) Breastfeeding, fertility and
population growth. In: Nutrition and Population
Links. ACC/SCN Symposium Report Nutrition
Policy Discussion Paper No.11, Chapter 4, p3347. ACC/SCN, Geneva.
UNICEF (1994) What the world's religions teach
about child nutrition and breastfeeding. BFHI
NEWS: The Baby-Friendly Hospital Newsletter,
December 1994. UNICEF, New York.
UNICEF (1997a) The Progress of Nations.
UNICEF, New York.
UNICEF (1997b) Norwegian entitlements give
parents leave to be with children. BFHI NEWS:
The Baby-Friendly Hospital Newsletter, May
1997. UNICEF, New York.
Villapando S and Hamosh M (1998) Early and
late effects of breastfeeding: does breastfeeding
really matter? Biology of the Neonate 74:177191.
Virtainen SM, Rasanen l, Ylonen K, Aro A,
Clayton D, Langholz B, Pitkanniemi J, Savilahti
E, Loumnamaa R, Tuomilehto J, Akerblom HK
(1993) Early introduction of dairy products
associated with increased risk of IDDMM in
Finnish Children. Diabetes 42:1786-1790.
Wellstart International (1992) Breastfeeding: A
Natural Resource for Food Security. Paper
prepared by Huffman SL, Rasmusson E,
Newman V, O’Gara C. Wellstart International,
Washington, DC.
WHO (1989) Protecting, Promoting and
Supporting Breastfeeding: The Special Role of
Maternity Services. A joint WHO/UNICEF
statement. WHO, Geneva.
Closing Comments
Richard Jolly: Thank you for that wonderful
demonstration and that wonderful example with
the pictures of your community leadership and
creativity. Thank you for so many good ideas
that I hope the SCN, as well as the individual
agencies, will find to act on. It was a wonderful
lecture and I thank you for it. I would like to give
Chapter 9: The Abraham Horwitz Lecture. Breastfeeding: From Biology to Policy
the final word to George Beaton to remind us
about Abraham Horwitz.
George Beaton: Thank you Mr Chairman. I want
to take this opportunity to say two things. One is
to again thank our speaker. When you started
speaking you said that you had received a fax
inviting you to speak and you were surprised,
then you were proud, then you began to wonder
why. Today you presented a lecture that said
that you should never have been surprised, you
should be proud, yes, but you should never ask
why. What you have done today, besides the
content— which was beautiful— is remind us why
we are in this room. It is to help people like you
on the front line— people who are really doing
things— that is why we exist. And I thank you
very much for your lecture and for reminding us.
Richard, I will now, if I may, turn to the lecture
itself and what it commemorates. I have had the
pleasure of knowing Dr Horwitz for quite a while.
What we must recognise is that what we
collectively know of him is his third career. He
really built his acclaim in Chile. He was a
fundamental builder of the health system in
Chile, which stood up very well. Through all that
happened in Chile, it survived. He was then very
important in building PAHO. He shaped the
structure and made it a force for the betterment
of health in Latin America. And that was his
second career. I recall when he left the paid staff
of PAHO, he was then looking for a third career.
In PAHO, he had become very interested in
nutrition. At one time, he even tried to recruit me
into the nutrition section. I didn’t accept, but he
did have a role in my life, because it was Dr
Horwitz who sent me on a short leave to
Guatemala, which got me interested in
international nutrition.
We must recognise the contribution that he made
to all of us collectively. Dr Horwitz served for 11
consecutive years and sessions as chairman of
the SCN, but he also served for four years before
that as chairman of the AGN. So we’re talking
about a 15-year span when Dr Horwitz was very
influential in this organisation. When I was
writing the SCN history, I contacted a number of
you for your recollections— favourable or
unfavourable— of the SCN, and what it was. I
was amazed at the number of comments I got
back about Dr Horwitz, all favourable. I will read
you only two of them because I think they are
very germane.
The first comment came from John Evans, who
was chairman of the SCN when Dr Horwitz was
Chairman of the AGN. John drew attention to Dr
Horwitz as a man, noting the �incredible example
of the intellect, integrity, diplomacy, and charm,
represented by the ageless Dr Horwitz’. And that
was the theme of many remarks.
I think of another thing that characterises his role
in the SCN. I think it was Leslie Burgess who
remarked that with the incoming of Dr Horwitz,
the SCN had a chairman who had the time and
the interest to really put into practice what the
SCN had said it wanted.
I think that Dr Horwitz as an individual, Dr
Horwitz as a leader in nutrition and Dr Horwitz as
a believer in the SCN are all commemorated in
this lecture and I hope you will join me in
celebrating Dr Horwitz and his life in nutrition.
Comment from the Reviewer
Coming from someone who says she is not an
expert, Isatou Jallow Semega-Janneh's article
has an unusually clear vision, unusually
innovative contributions to make, and is a
welcome addition to the breastfeeding literature.
She rightly emphasises the fact that exclusive
breastfeeding without even additional water is
necessary if the benefits of breastfeeding are to
be fully realised. As the ACC/SCN has earlier
emphasised— it is not being stunted but the act
of becoming stunted that is harmful, and yet it
starts throughout the developing world almost
from birth. Little relevant research has been done
yet, but one could hypothesise that if too much
water and other fluids are given, breast milk will
be displaced to the point where protein and/or
mineral levels in the infant diet will be inadequate
to achieve ideal increases in stature, even in the
absence of frank illness and malnutrition.
She is equally correct to point out that exclusive
breastfeeding for about six months cannot be
achieved unless the newborn baby and mother
receive more support than we have recognised in
the past was necessary and important. She
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
mentions economic arguments for longer
maternity leave but one could also view it from a
human rights perspective. If we now agree that
the life of school-age children should be
protected from harm done by child labour, is it
any more acceptable for a baby’s life to be
harmed through unreasonable work demands
placed on the mother in the early months of life?
We have an historic opportunity now to rethink
this issue, as the ILO will reconsider Convention
103 on Maternity Protection at its next annual
meeting in June, 1999.
would already have everywhere in the world if we
had built up social systems that had taken into
account the importance of exclusive
Given how rare it is that one comes across really
new and creative ways of approaching
breastfeeding promotion, it was a pleasure to
read the amazing number of fresh ideas Isatou
Jallow Semega-Janneh proposed for both
international and national levels.
Is this approach reproducible elsewhere? Like all
innovative projects, there is a risk that a dynamic
person or small group was responsible for much
of the impact. But one hopes that The Gambia
will move ahead with its plans for national
implementation and lead the way for the rest of
the world!
Even more refreshing was how The Gambian
Baby Friendly Community Initiative ignored all
the usual limitations that keep breastfeeding
promotion limited to the health care system, and
moved out to the villages. The inclusion of men
in the village groups was also a crucial
innovation. Only if everyone realises the
importance of maternal-infant proximity will it be
possible to mobilise the necessary support. The
idea of setting up baby-friendly rest houses in the
fields where the mothers worked was also truly
ingenious. Though less widely adopted in the
trial, the "community maternity leave" concept
sounds like the kind of long-term solution we
It was also a pleasure to see that some kind of
evaluation research was linked to the initiative
from the beginning. The results, as the author
herself says, were of an unexpected magnitude.
While there was no control group, one can be
fairly certain that such a large secular change in
breasfeeding practices do not occur.
One wonders what kinds of innovative efforts
would be tried now if [the author] had been
running a global effort to cope with the problem
of HIV transmission through breast milk.
Presumably she would soon have determined
how and where heatment of expressed milk, use
of wet nurses, and milk banking might be used
as first priority approaches for reducing the risk
of mother-to-child transmission of HIV without
risking so many infant lives and damaging public
confidence in this most irreplaceable of human
Chapter 10: General Discussion
Chapter 10
General Discussion
Fernando Antezana (WHO): The history of
humankind provides powerful messages for us
about the central importance of food in sufficient
quality and quantity for the development of
Since populations began
aggregating in towns and cities, their livelihood
has depended directly upon access to a safe and
adequate supply of food. When supplies have
been restricted due to climatic factors, war, or
civil unrest, the overall quality of life and sense of
collective security have diminished. Now, at the
dawn of the new millennium, we face the real
opportunity of ending malnutrition within the
relatively short period of two decades. This
would ensure that the world’s most vulnerable
populations are not deprived of one of the most
fundamental rights of human beings, namely the
right to adequate nutrition.
We are pleased with the draft report of the
Commission and, in particular, commend the
authors for embedding in their report many of the
core components of WHO’s new global health
policy �Health-for-All in the 21st Century’.
Through the global consultative process, based
strongly on the views of Member States, NGOs,
and a wide range of other national and
international bodies, it is not surprising that of the
ten global targets defined in the new policy, the
first target emphasises both equity and nutrition.
The Commission report gives emphasis to equity
and to the close links between many recent
international instruments dealing with human
rights. It also implicitly recognises that there is
an ethical imperative to provide food for all.
While not explicitly mentioned, the report also
implies the need for a gender perspective in
dealing with many aspects of food policy. WHO
urges that a more explicit gender approach be
incorporated into the development of food and
nutrition policy.
The Commission report gives particular
emphasis to integrating and amplifying the
United Nations’ efforts in respect of nutrition
policy. It highlights the need for intersectoral
action in order to achieve food security.
Similarly, the new global health policy calls for
health to be placed at the centre of concerns for
sustainable human development.
From a
nutritional point of view, this implies looking for
particular synergies in the goals and actions of
the agricultural, energy, transport, educational,
and health sectors. The emphasis on agriculture
is appropriate. In addition, we would recommend
that the Commission consider closer interaction
between energy use and production, bio-diversity
loss, and production of food. At a household
level, many countries still use biomass as their
major fuel for cooking. This is associated with
increased risks of acute respiratory infections,
burns, and poisoning. Safer means of energy
use and indeed, safer kitchens, should also be a
component of improving food security.
WHO supports the strategies recommended for
enlarging the crop mix in food systems. WHO
also supports potential gains for health through
the use of new biotechnologies. Clearly, a
careful evaluation of their long-term health
impact will be required. As with all forms of new
technologies, a major challenge will be to ensure
that the benefits are made rapidly available to the
poorest sectors of society and to the poorest
countries. Already the agricultural sector has
played a vital role in improving the productivity
and quality of food worldwide.
Data are emerging from several developing
countries to indicate that the rate of nutritional
transition is occurring rapidly. This implies that
children who are malnourished will, in their forties
and fifties, suffer from obesity, diabetes, and a
range of cardiovascular diseases and cancers.
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Our collective response needs to ensure that the
ischaemic heart disease epidemics of the
developed world are not repeated throughout the
developing world. Rather, greater emphasis
needs to be given to preventative and promotive
measures that include appropriate regulatory and
fiscal strategies aimed at promoting healthy
diets. The goal should be to introduce those
policies that make healthy eating an easy choice.
This includes for example, using the successes
of Finland and Norway in developing a
combination of pricing and regulatory policies
that favour fruit and vegetables over meat and
dairy products. The experience of Poland is also
important in this respect. By the latter part of the
1980s, the rate of ischaemic heart disease
continued to rise significantly. Subsidies on meat
and dairy products were dramatically reduced to
increase government revenue. The result has
been that fruit, vegetables, and fish products
have become relatively more affordable with a
concomitant rapid and sustained decline in
ischaemic heart disease death rates. In contrast,
many countries continue to subsidise high fat
products and fail to support marketing
approaches that would make a wider range of
healthier foods available to the poorest sectors of
the community.
In addition to nutrition policy, the control of noncommunicable diseases will require stronger
linkages between those involved in tobacco
control and nutrition. Tobacco use, a high-fat
diet, stress, physical inactivity, and hypertension
work together to increase the risks of ischaemic
heart disease. Tackling one factor in isolation
may not reduce the overall impact of these
With respect to food safety, the Commission
report briefly indicates how we face a range of
new threats and problems. Never before has so
much food been produced so far from the place
where it is consumed. The globalisation of the
food trade has profound implications for how we
ensure food safety and security across borders.
At the global level, the Codex Alimentarius
provides an outstanding example of international
cooperation between FAO and WHO in
developing and ensuring food standards for the
protection of all. Moreover, the provisions in the
Agreement on the Application of Sanitary and
Phytosanitary Measures, which entered into
force with the establishment of the World Trade
Organization on 1 January 1995, acknowledge
the work of the Codex Alimentarius Commission
as the reference for national food safety
requirements. Countries that are members of the
World Trade Organization may no longer reject
foods that meet Codex standards, guidelines,
and recommendations without providing
justification. Despite this, it is likely that food
safety issues will become even more important in
trade disputes over the next few years as the
pace and volume of food trade increase.
Issues of food safety have already emerged as
being of the highest political concerns across a
wide range of countries. Within Europe, I do not
need to emphasise this further than mentioning
BSE. In the Americas, contaminated raspberries
and strawberries have resulted in important trade
disputes between the USA and countries of Latin
America. In Japan, concerns about food safety
have similarly resulted in major efforts to
strengthen the national capability. African
countries have experienced the negative effect of
how food safety standards can be abused.
While several European Union countries initially
rejected fish from cholera infected countries in
Africa, the public health basis for this did not
exist and the Codex Alimentarius was able to
provide a balanced view of the true nature of the
threat. Also, measures exceeding those outlined
in the International Health Regulations resulted in
the loss of approximately US$ 770 million for
Peru when its trading partners boycotted its
products during the 1991 South American
cholera epidemic, which began in Peru.
WHO and a range of other agencies are working
to strengthen food safety in an exciting project
entitled �healthy markets’. The intent is to bring
together our knowledge and skills about
improving basic hygiene and work with those in
the market places of all countries, starting in the
developing countries, to show that simple costeffective measures can be taken to improve the
quality of food consumed.
Within health systems, nutrition is highlighted as
a priority for action. The focus on life span
approaches to health is echoed in the
Chapter 10: General Discussion
Commission report and strongly emphasised in
the new global health policy. The lifespan
approach to health starts from conception of a
child in utero. Increasing evidence suggests that
the quality and quantity of food provided from
birth and, in fact, the mother’s level of nutrition
during pregnancy, have a profound impact on a
child’s subsequent health. Getting the balance
right in the first few years of life will be a major
challenge. Furthermore, with the realisation that
breastmilk may transmit HIV from mother to
child, WHO is examining the scientific evidence
to ensure that it provides the most appropriate
and the safest policy recommendations to
It is not only the quality and quantity of food that
are important. The social context and quality of
caring that occurs in the family also has
implications for subsequent health and
development of children, young adults, and
adults. Thus, we urge that the important
interaction between social determinants and
adequate nutrition be given closer attention in
future research and policies. The overall quality
of caring that occurs in the household influences
the intellectual, physical, and emotional
development of children.
In addition to care, WHO’s new global health
policy calls for a stronger commitment to
essential public health functions. These are as
essential for nutrition services as they are for all
other aspects of care. To highlight only two
public functions here: information systems and
human resources. Health information and
surveillance systems provide the means of
alerting countries to impending crises and
evaluating the success of interventions. The
sensitivity of nutritional indicators to
macroeconomic climatic factors and diseases
demands that they be at the core of surveillance
systems and be based upon globally-derived and
scientifically-based standards. In this context,
the new WHO growth references will, for the first
time, be based on data collected from a cohort of
children who were breastfed and born to nonsmoking mothers.
Services are built with competent people in
strong institutions. The policy highlights the need
for a stronger, reinvigorated approach to human
and institutional capacity for health. Improved
morale, better training, and continuing education
apply to all those involved in nutrition services.
Importantly, the policy emphasises that basic
skills in key public health disciplines such as
epidemiology, health economics, and public
health law will benefit all content areas, including
In conclusion, I would like to commend the
Commission on its draft report, and particularly
the emerging issues and concepts it highlights. I
would like to end by reiterating the importance of
issues such as food security at household level,
food safety, the Codex Alimentarius, the
globalisation of food trade and the WTO, and
essential public health functions.
Ernest Loevinsohn (CIDA): Being reminded of
the nutrition goals for the years 2010, 2015, and
2020 made me consider the chain of broken
promises that have already been made to the
hungry children and malnourished mothers of the
world. This is an unhappy tradition that goes
back at least to the early 1970s with the World
Food Conference and perhaps even earlier. At
the World Food Conference they said that "today
we proclaim a bold objective, that within a
decade no child will go to bed hungry."
I think we want to do more than proclaim bold
objectives; we want to perform bold actions.
Certainly the malnourished people whom we are
trying to serve would prefer that. One of the
most important areas for bold action is in
advocacy with decision-makers.
There are two stages in advocacy: the first is
clarifying what we want to advocate for, and the
second is the actual persuasion. In terms of the
first stage, we need to determine what our
priority messages are. How do we prioritise? I
would suggest that we focus on the empirical
evidence of which nutrition interventions are first,
efficacious, second, cost-effective, and third,
In terms of the persuasion stage: the regional
meetings that the Commission report proposes
will have an important role, but to be effective
persuaders, we have to think in terms of each
decision-maker. Whom do they have to listen to,
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
and whom do they want to listen to? In short,
how can we reach them? We need from the
Commission a concrete programme for lobbying,
that is realistic in terms of available resources.
There is one particular area that I would like to
highlight where we might get some early
successes from lobbying. That is the food aid
business. This includes donors shipping food
from their countries to developing countries,
donors who spend money to buy food in
developing countries, and most importantly those
countries who have food distribution or subsidy
programmes for their own populations.
You can spend a long time with people in the
food aid field without hearing much about
nutrition. This is a little odd, since this multi-billion
dollar effort is being paid for by taxpayers under
the heading of doing something about hunger.
There is a lot of potential to get "more gain for
the grain" from food aid. In the UN system we
could start with the World Food Program. There
are some very encouraging signs, as the
Executive Director of WFP has said that she
wants a focus on malnutrition with a view to
"ending the inheritance of hunger". She wants to
concentrate on women first. But there is still
some way to go in terms of implementing her
vision on the ground, and some lobbying there
might be a good way to proceed. For our part in
Canada, we are trying to stay true to our pledge
to make nutrition central to what we do in food
aid, and to measure results using nutritional
indicators— anthropometric and other.
Of course food aid is just one example of the
opportunity for nutrition lobbying. To summarise,
if we are going to have an effective programme
of advocacy on nutrition, firstly, we have to
prioritise our messages based on the empirical
evidence. Secondly, we need a practical
advocacy plan from the Commission.
Some of you may be familiar with Benjamin's
Law: When all is said and done, a lot more is
said than done. What I would like from the
Commission is a focus on action— on specific
effective action— so that when their work is done,
we can say that this was a shining exception to
Benjamin's Law.
Bill Clay (FAO): FAO endorses the concept of a
gender perspective. A gender perspective in
nutrition is needed. The theme of the World Food
Day in 1998 was �women feed the world’. We
strongly emphasise the need to recognise that
nutrition wellbeing is important— not only in its
own right, but also in making a contribution to the
future generation and to society at large. All too
often, women have been seen simply as vehicles
for producing, caring for, and feeding children.
Without sufficient attention given to the other
human development considerations, there is a
clear need to recognise the context and causes
of childhood malnutrition. How these can best be
addressed starts with the recognition of the
importance of women in nutrition. It is only
through good nutrition and health of women
during pregnancy and of children during early
childhood that the next generation will achieve its
fullest physical and mental potential.
It is not acceptable that hundreds of millions of
children are already condemned at the moment
of birth to physical handicaps, higher propensity
to disease and to impaired intellectual abilities.
Low birth weight begins the cycle of hunger.
This cycle must be broken.
malnutrition is of major economic significance
and better nutrition is a fundamental investment
for economic development.
FAO considers that a gender perspective on
nutrition must recognise the crucial role that
women play in securing, preparing, and serving
food for themselves and others.
International Conference on Nutrition Plan of
Action stated that �women need to constantly
balance the reproductive, nurturing, educational,
and economic roles, which are so important to
the health and nutritional wellbeing of the
household and of the entire community’. Women
are the main providers of meals, care, and
nutrition information in the household, and they
have a fundamental role in ensuring improved
nutritional status for all. The importance that
gender has on individual, family, and community
nutrition and wellbeing was further emphasised
during the World Food Summit (WFS). A specific
objective of Commitment One of the WFS Plan of
Action is �to ensure gender equality and
empowerment of women’. This has been
instituted as a guiding principal underlying FAO’s
Chapter 10: General Discussion
programmes. It has also strengthened the
overall FAO efforts to promote community-based
household food security and nutrition
Women need to be able to participate fully in the
decisions that affect their nutritional wellbeing
and welfare. This begins by ensuring that girls
receive a fair share of their parent’s time,
attention, affection and resources, including food
and nurturing. Girls must not be denied access
to quality education, health care, and social
opportunities as they mature and become
productive members of society.
contribution to family and community must be
valued appropriately. FAO fully endorses these
propositions and commits itself to working with its
member countries and other development
partners to promote the nutritional wellbeing of
women and to strengthen their capacity to
promote the nutrition and welfare of the next
We appreciate the emphasis that the
Commission places on poverty and social
discrimination as being at the core of the most
serious nutrition problems throughout the world.
We also recognise that we cannot wait for
poverty and food insecurity to be eliminated
before taking action to improve nutrition. We
endorse the need to provide specific actions to
meet the nutritional needs of special groups.
Even so, this does not diminish the importance of
agriculture and economic development in
eliminating hunger and malnutrition. Nor does it
minimise the fundamental importance of
addressing food and income issues. The major
resources available in many poor countries are
their agricultural potential and their human
population. Investment in both is necessarily
mutually reinforcing.
Expanding agricultural development, including
fisheries, forestry, and livestock leads to
increased community and national wealth as well
as improved individual incomes. It is this wealth
creation that can improve the conditions for more
sustainable access to food and to support the
schools, the clinics, the social services and the
physical infrastructure necessary to sustain
lasting improvements in nutrition. Without such
development, the poor and undernourished will
simply be consigned to receiving handouts.
Dignity, hope, and self-reliance will be lost.
It is important to recognise the extensive
problems of iron deficiency anaemia and other
micronutrient deficiencies. Small-scale farming
systems are important to income generation.
Regarding the concept of dietary diversity, we
should not be overly focused on crop
diversification and minor crops at the homestead
or local level. While home gardening can be an
important aspect of diet diversity, a balance
needs to be maintained in advocating other
agricultural systems that generate income, and
with well-functioning and efficient markets to
enable consumers to diversify their diets through
trade at the local level. These aspects become
even more important in urban and peri-urban
areas and among the landless rural dwellers.
Dietary diversity can be achieved through
additional purchases as needed. In brief,
consuming a diversified diet is not dependent on
each household producing a diverse bundle of
The issue of global trade liberalisation, especially
in agricultural commodities, is also a very
important and complex issue. For example,
higher world market prices for food imports,
which may result in a reduction in production
subsidies in developed countries, should benefit
developing country food producers, but may not
necessarily have immediate benefits for
consumers in those countries. FAO is working in
this area with regard to the Uruguay Round
follow-up. This includes providing technical
assistance to developing countries to enable
them to be equal and well-informed partners in
the process.
Rolf Aspestrand (UNDP): Poverty reduction is
the highest priority of the United Nations
Development Programme (UNDP), and, as has
been stated several times here, nutrition has an
important role in the process of poverty
alleviation. This also links to UNDP’s work on
building national capacity in the area of nutrition
at country level.
UNDP has governance
programmes, where the links with the national
governments can be strengthened, and we have
to work on that. In the area of good governance,
the UNDP has recently published a policy
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
document �Human rights: integrating human
rights with sustainable human development’.
This new document looks at the links between
human rights and development, and includes
food security and nutrition.
It has been pointed out by Dr Brundtland,
Professor James, and the Minister of
Development in Norway, Dr Hilde Frafjord
Johnson, that we need to coordinate our efforts
and act together as one body. We should not
have the situation where one country receives
3000 development projects and has to try to
please 30 different agencies. That is not
constructive. In this respect, UNDP is happy to
support the coordination of agencies through the
resident coordinators. UNDP also supports the
country-level monitoring of human development
progress. You may be familiar with the Human
Development Report and its human development
I also would like to mention the follow-up to the
2020 Conference that was held in Oslo in 1995.
The 2020 concept was introduced in the Human
Development Report in 1995 and is something
that the Norwegian government strongly
supports. The first follow-up conference was in
Hanoi, Viet Nam, in October 1998. The
concept— trying to set aside 20% of the national
budgets for basic social services, and having the
donor agencies allocate 20% of their budgets on
basic social services, is also something that
UNDP supports.
Barbara Underwood (IUNS): The IUNS is taking
a 21st century look at its function and trying to
define ways in which the nutritional science
community might enter more actively into these
processes of carrying out an agenda appropriate
to the global concerns in nutrition in the next
millennium. Philip James, Julia Tagwireyi, and
Ricardo Uauy are all on this IUNS Council, and
Ruth Oniango is a member of a special
committee considering how IUNS can be
repositioned to more effectively meet the
challenges of the next century. I simply want to
say that the nutritional science community,
through the IUNS— which represents some 69
different countries— stands ready to assist in
carrying out what I think is a visionary agenda for
the 21st century.
Nevin Scrimshaw (UNU): There have been many
UN and SCN documents on the world food and
nutrition problem over the years— some of them
have been very useful— others have been so
loaded down with caveats and details that they
are of little value. I think it is clear that we do
now need a balanced, updated, contemporary,
constructive statement for planning of nutrition
activities into the next century. The UNU feels
that the Commission has produced this kind of a
document in draft. If the report became loaded
down with the details that every agency wanted,
we would have an �over-decorated Christmas
tree’. It would then lose its value.
Inge Nordang (Norway): In light of the interesting
speech made by the Norwegian Minister, Dr
Hilde Frafjord Johnson, there is really not much
more to add. One of the most outstanding issues
in this symposium is the poverty issue. This has
been an underlying problem in the agendas of all
the major UN conferences and summits through
the 1990s. It is necessary to go into the poverty
processes and look at what is behind the poverty
mechanisms. We should not always try to attack
the symptoms only. I find it interesting to look at
marginalisation as a major poverty mechanism at
different levels. When trying to find remedies,
the key word is �empowerment’. This has been
very elegantly shown in several of the
presentations. We have seen what is happening
in Africa as a result of social marginalisation
leading into poverty.
There is also the issue of women, which is at the
centre of this Symposium. In most societies,
women are marginalised. We have also been
discussing geographical marginalisation, for
example, Per Pinstrup-Andersen pointed to the
importance of geographical marginalisation. If
you want to do something about poverty, then
you have to attack that.
Richard Osborn (UNFPA): The United Nations
Population Fund is a small operation, which
focuses largely on supporting reproductive health
services for women. As a fund, we respond to
what national governments bring to us by way of
requests for programmes. In my capacity as the
senior technical officer at UNFPA, I don’t recall a
single programme coming to us with a
component on nutrition as having an impact on
Chapter 10: General Discussion
maternal health. So when we look at our
programming, which begins with adolescence,
carries on through the reproductive years and the
major period of child bearing, we find no
evidence of concern for nutrition being brought to
us. We are simply not presented with demands
for inclusion of these variables within our
Why has this occurred? On what basis would we
advocate to governments that they should be
concerned about nutrition? What data are
available? Before coming to this meeting, I
looked at the Cochrane database that is now
available on disk from the WHO reproductive
health library. In one review of the impact of
social support, the conclusion is that pregnant
women should be informed that programmes
offering additional support during pregnancy are
unlikely to prevent the pregnancy from resulting
in low birth weight or pre-term infants, and are
unlikely to improve other important outcomes. In
a review of protein energy supplementation and
pregnancy, the conclusion is that balanced
energy protein supplementation modestly
improves foetal growth, but is unlikely to be of
long-term benefit to pregnant women or to their
infants. There seems to be a stronger base
when we look at some of the areas such as
iodine supplementation where there has been a
positive impact. But in short, looking at the
available scientific database, I do not have
information on which I can advocate to
governments. I cannot rely on observational
data alone.
There is clearly a need for
appropriate scale, well-defined clinical trials to
provide the evidence on which we can base
policy and programmes. I cannot advocate
without an appropriate database of clinical trials.
Within my own organisation, although we talk a
great deal about gender, we are still really
referring to women’s programmes, i.e., it is not
role-related specific behaviours that are being
programmed. We should not merely focus on
the early stages of the life, but we should also
consider that the elderly are an increasingly
important group.
In closing, I would like to remind you that 1999 is
the fifth anniversary of the Cairo Population
Meeting. One question that I would like to ask to
you, is when I am putting together the agenda
and laying out the outline for what will be the
Secretary-General’s report to the special session
of the General Assembly, should there be
mention of nutrition in the area of population— in
particular, in reproductive health? If the answer
is yes, then I really need better information and a
better set of arguments than I can find available
in my current literature.
Richard Jolly (SCN Chairman): I think you have
issued us with many challenges and your very
first reference to there not being a single project
asking for support for maternal nutrition is a very
thought-provoking comment.
Roger Shrimpton (UNICEF): I would like to give
some reflections on the Symposium. UNICEF,
as a humanitarian and developmental agency, is
guided by the Convention on the Rights of the
Child, and I would like to talk about rights-based
approaches to programming as an overall theme
and give some examples of how programmes
can be implemented from a practical perspective
in the field. There are five issues that I would like
to talk about: breastfeeding, local government
implementation of nutrition goals, governments
and rights, prioritisation, and follow-up.
The eloquent presentation by Isatou Jallow
Semega-Janneh was a wonderful reminder for all
of us of how important breastfeeding is. We
should all remember, of course, that
breastfeeding is a right for all children as stated
in the Convention of the Rights of the Child,
which has been signed by all governments. It is
an important obligation of all governments to
protect, promote, and secure breastfeeding.
I wanted to talk also about local government as a
way of achieving goals. The presentation by
Suttilak Smitasiri described the ways by which
nutrition goals were achieved in Thailand. The
�what’needs to be achieved and decided at the
national level, but �how’ that is achieved was
worked out at the local level. Suttilak described
the importance of looking for the �windows of
cultural opportunity’ that are there, but these
differ according to the setting. So �how’ you
achieve goals is something that needs working
out at the local level. Often intersectoral
responses are needed not just health sector
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
responses. Recently I read in an editorial of the
British Medical Journal, that the British
government is taking a new approach to health. It
recognises that achieving health goals cannot be
done only through the health sector, and that the
basic causes must be addressed. The British
policy proposes something very similar to the
approach used in Thailand, which is that at the
local government level, local government, health
care providers, and civil society should work out
the process indicators.
So there are
commonalities across various societies about
how you can achieve these goals— that are not
just sectoral goals but that are society-based.
Thirdly, I would like to talk about governments
and human rights. I would like to explain how a
rights-based approach was developed in
Indonesia for achieving maternal mortality
reduction. By getting the Indonesian government
to agree on the implementation of the
Convention on the Rights of the Child, and the
Convention on the Elimination of all Forms of
Discrimination Against Women (CEDAW), as a
priority in its work with UNICEF, we developed a
two-pronged strategy. One arm of this was a
mother-friendly hospital movement, and the other
was a mother-friendly sub-district movement.
This reminded me very much of the
breastfeeding community initiative presented by
Isatou. Now, throughout Indonesia, there are
movements at the district and sub-district level.
By putting CEDAW into that sort of context and
by getting local governments to understand what
CEDAW is and to appreciate their obligations to
achieve what is in CEDAW, are ways of
addressing the gender perspective through the
life cycle. As organisations, if we can increasingly
refer to the conventions on human rights and
especially the Convention on the Rights of the
Child, and the Convention on the Elimination of
all Forms of Discrimination Against Women, and
perhaps less to our global seminars and our
global goals, which are important sectorally, this
will help us come together also at the country
level. UNICEF strongly supports efforts to
increase coordination of agencies at the country
level through UNDAF (United Nations
Development Assistance Framework) process.
We believe that the combination of a rightsbased approach and the UNDAF process will
help agencies work together better in the pursuit
of common nutrition goals.
I also wanted to say something about
prioritisation. I have worked as a nutritionist in
the field for 25 years. I continually hear the
reference by some people to bullet approaches
as being not sustainable, and to food-based
approaches, as if these were things were an
either/or. This is not helpful if you work in
programmes. If one takes a rights-based
approach to nutrition and there is an immediate
need, then there is a need to go in with an
immediate response, which would be
appropriately a supplement. A rights-based
approach would endorse that. Food is also part
of a rights-based approach, but those responses
perhaps take longer. So recognising immediate,
underlying and basic causes, and the need to
have all of those responses ready, is important.
It should not be an either/or in relation to
supplements, food fortification, or food-based
Finally, UNICEF is considering developing
approaches to reduce low birth weight. We have
begun some discussions with the World Food
Programme to see how we might work together
on that. This is an important area and we are
prepared to begin developing programmes in
Southern Asia, especially in Bangladesh. The
UNICEF country programme in Bangladesh has
low birth weight reduction as a priority because
Bangladesh has 50% low birth weight, and as
such, is the leading country for low birth weight in
the world.
Tom Marchione (USAID): I am impressed by,
and would recommend the work of Roger
Shrimpton in community participation and
involving the local community in nutrition
programmes. After a decade or so of state
disempowerment, especially in developing
countries, it certainly is appropriate, as Per
Pinstrup-Andersen said, that the State needs to
be re-empowered to fulfil its functions and
provide the infrastructure necessary to have a
viable programming environment. On the other
hand, let’s not place too much emphasis on the
Central State and not enough emphasis on the
means of enabling and nurturing local
programming, such as those we have heard
about in Thailand and The Gambia, which are so
Chapter 10: General Discussion
impressive. The assumption that decisionmakers are people at the heads of organisations
seems to me to be myopic. It is important to get
to decision-makers within communities, and we
should think more in terms of a plan that enables
this process. It might not have been so realistic
to try to do this in 1955 or 1975, but I think that
now, with the spread of democratisation and the
freeing of civil society, we really have to think
more in terms of how to facilitate and build on
what is already happening.
George Kent (World Alliance for Nutrition and
Human Rights): I appreciate very much
UNICEF’s strong orientation towards the rightsbased approach and have a few comments
about what Roger Shrimpton said. One of my
first concerns is that Roger began with a rather
unconditional statement about breastfeeding
being a right for all children. Those of us working
on the issue find that problematic because it
conflicts with the right of the mother to choose.
We are trying to work out some language to
resolve that conflict. Second, I am slightly
concerned about the notion of interpreting
participation in terms of having goals set centrally
and then implemented locally. I think it is
important to insist on participation from the
localities in the formulation of the goals as well.
In the formulation of rights, my position is that the
human right to food and nutrition implies a
particular entitlement to some kinds of goods or
services. Accompanying that are legal remedies
such that if one does not get what one is entitled
to, then there will be some mechanism in place
for correcting the situation. Without that I think
we are not talking about human rights and I think
that needs to be spelled out more clearly.
Philip James (Commission): A recurring theme is
the centrality of the issue of human rights. We
have already discussed the way by which we
approach this— what we need to do is move into
the practical dimension of what this actually
means. We need to spin that into effective
mechanisms whereby those rights are displayed
and acted on. There are fundamental issues of
human rights, but how do we put that into a
coherent framework that has logic in terms of
I was fascinated by what UNFPA said regarding
the lack of a scientific basis. I believe that the
scientific analysis is incomplete as displayed by
the Cochrane reviews. This brings up a
fundamental question. If observational data are
no longer the basis for action, then are we
demanding double-blind placebo-controlled trials
before we get action? What level of evidence do
we need before we actually specify a particular
route of action?
Concerning the poverty dimension, quite often
progress had been made without economic
transformation. If we just go down the poverty
agenda, we would be missing a huge opportunity
given the evidence that material progress can be
made, for example, in childhood malnutrition,
without having an enormous increase in GDP.
Certainly the Asian experience suggests that
there is not a powerful concordance between
economic gain and nutritional improvements.
Julia Tagwireyi (Commission): I come from a
programme planning perspective. In looking at
what the 21st century holds, I have to personalise
that experience. It is a challenge facing us at the
country level. More of the same will not do
because the context is changing so rapidly—
especially in Sub-Saharan Africa. Those very
communities that we have depended on for their
activity and action at the community level— their
coping strategies are diminishing so rapidly. The
disease burden— particularly with AIDS— is going
to affect all those things we are doing in the
communities— it is in fact already doing so. It is
reducing the little capacity we have in terms of
technical people. That is a challenge for us in the
21st century because we are dealing with
communities that are getting fragmented
because of the heavy disease burden— in
particular, AIDS.
Communities in many
instances in Sub-Saharan Africa, are no longer
able to cope— their coping strategies are
diminishing daily. Governments and other
stakeholders in countries may need to wake up
to see how they can help their communities
bolster their coping strategies so that they can
continue to help themselves. I don’t think I am
exaggerating— this is the reality that we are living
with. We have to challenge ourselves and ask
how we cope with this. We want improvement—
we are all frustrated by the decline or stagnation
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
in nutrition improvement. At the same time the
situation has changed and the context is more
difficult in terms of operating. Are we up to that
George Kent (WANHR): There seems to be a
common sense of fragmentation to this effort. If
we think about it in terms of a rights approach
that implies a goals approach, and the goal is to
end malnutrition, then the task is to have a
strategic plan with an acknowledgement of the
kinds of resources we have available. The
problem with the resources that we have
available is that they tend to go in different
directions. There is not a single strategic plan.
Imagine for a moment if we were to contract out
this task— ending global malnutrition. Imagine
what we might get if we put out a request for
proposals for how to end global malnutrition.
Imagine also that we would pay the contractor on
a contingency basis. We will check on the
contractor’s performance every three years and
give an incremental payment as the work moves
ahead. And there will be sub-contractors. We
have the sub-contractors represented here, but
there isn’t a master contract. Perhaps if we
could think of the task as preparing the master
contract. We don’t need the technical details of
how the cement pourer has to formulate his/her
cement— the cement pourer has that expertise
and we can leave that to him/her. What we are
talking about is performance contracting— you
deliver a certain performance and we will hire
you. I think we should hire bridge builders to
figure out how to shape the task with the
intermediate steps, with the sub-contracting and
so on.
Richard Jolly (SCN Chairman): I’m not quite sure
where governments and the community come
into the analogy of the sub-contractors. I can
see how the UN agencies are there, but there
are a lot of gaps between the UN agencies, the
countries, the people.
Urban Jonsson (UNICEF): There is something
incredibly important that has happened over the
last 12 months, and that is the UN reform. The
need to work together and harmonise policies
and strategies is the biggest challenge for the UN
just now. And we have the mechanism to do
For years in the SCN Working Group on
Nutrition, Ethics and Human Rights, we allowed
ourselves to ask �do we really accept a human
rights approach?’ Forget about the discussion—
it’s over. It is not optional any more. It is very
clear from the Secretary-General in the reform
process, that the UN is an organisation based on
human rights. There is no option any more. It is
up to us to interpret that and operationalise it
within the framework of the United Nations
Development Assistance Framework. So in that
sense, I think we really have an opportunity to do
something extremely important within the UN. If
we do it well, not only will we show the way for
others, but it will bring nutrition higher on the UN
agenda. We have somehow been training for
this for the last 20 years, so we ought to be able
to do our homework well.
There is an enormous amount of material on the
care initiative. We have discussed poverty and
nutrition. Let us not reinvent the wheel every
time— sometimes we should do it, but not every
time. There is a wealth of material and
agreement on what the relationship is. Finally, I
am very sad when I hear people saying that
nothing happens and that there is no success. I
think many of us would disagree with that. So
many good things have happened, with so many
interesting successes around the world. The
SCN has been at the forefront in the nutrition
world to document it over the last 12 years.
Community-based programmes, country-level
programmes— it’s a wealth of information, that
almost makes us say �let’s declare victory’. We
start to know what works. But then Julia says
“more of the same is not enough”. What is “more
of the same”? The same is not what we have
identified in SCN as success because most
governments do not adopt the right strategies.
Let us not develop new strategies, but let us
make governments adopt the right strategies. I
don’t think we need much more time to think
about what is right and what is wrong. We have
done this over the last 10 years and we have a
certain consensus. The problem is that the
governments do not accept it. So there is
another level in getting these strategies
Judy McGuire (World Bank): We have one
example in the world of a very successful effort
Chapter 10: General Discussion
to get the UN agencies moving— that was the Rio
conference, which was about the environment.
The reason why they got action going had
nothing to do with anything signed by UN
organisations. It was because the NGO
community got together and made a lot of fuss
and put a lot of pressure on UN organisations,
and made them accountable and made them do
their jobs.
Lilian Marovatsanga (AGN): I come from a
developing country where the problems are
getting worse, and I am not convinced that when
I leave this room I will be able to say what we
have achieved so far. We have the solutions to
most of the problems, but our own limitation is
that when it comes to practical implementation, it
seems to be crisis management all the time.
There is no strategic planning in nutrition. We
need to be business-minded and approach the
problems in an organised manner. In Zimbabwe,
between November and now, so much has
happened because of the crash— a 70%
devaluation of the dollar— creating a food crisis.
There are now riots. We have seen this happen
also in Indonesia. We should draw on lessons
learned so that we can manage nutrition
problems. We have to build the business aspect
into the way in which we plan our programmes
and this requires a strategic plan.
Challenges for the 21st Century: A Gender Perspective on Nutrition Through the Life Cycle
Information on
ACC/SCN Nutrition Policy papers,
as well as additional
copies of papers,
can be obtained from
the ACC/SCN Secretariat.
Enquiries should be addressed to :
ACC/SCN Secretariat
c/o World Health Organization
20 Avenue Appia
CH 1211 Geneva 27
Email: [email protected]
Fax: +41-22-798 88 91
Telephone: +41-22-791 04 56
Challenges for the 21 st Century: A Gender Perspective on Nutrition Through the Life Cycle
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